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UNITED STATES OFAMERICA. 






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ORTHOPEDIC SURGERY. 



^HHM^^H 



MANUAL 



OF 



ORTHOPEDIC SURGERY, 



BEING 



A DISSERTATION 



WHICH OBTAINED 



THE BOYLSTON PRIZE FOR 1844, 



ON THE FOLLOWING QUESTION: 

IN WHAT CASES AND TO WHAT EXTENT IS THE DIVISION 
OF MUSCLES, TENDONS, OR OTHER PARTS PROPER FOR 
THE RELIEF OF DEFORMITY OR LAMENESS?" 



BY 

HENRY JACOB BIGELOW, M. D 



" Eripiunt omnes * * ** * * sine vulnere nervos." 

Otid. Remed. Amoris, V. 147. 



BOSTON: 
WILLIAM D. TICKNOR &, CO 

CORNER OP WASHINGTON AND SCHOOL STREETS, 

MDCCCXLV. 






<o 



Entered according to Act of Congress, in the year 1845, 
By William D. Ticknor &. Co. 
In the Clerk's Office of the District Court of the District of Massachusetts. 



Butts, Printer, Boston. 



The following votes were adopted by the Boylston Committee in 
1826 : — 

1. That the Board do not consider themselves as approving the 
doctrines contained in any of the dissertations to which the premium 
may be awarded. 

2. That in case of the publication of a successful dissertation, the 
author be considered as bound to print the above vote in connection 
with it. 



PREFACE. 



The works I have consulted in writing the following 
Dissertation, are chiefly those of Guerin, Bonnet, Vel- 
peau, Phillips, Duval and Little ; especially the bro- 
chures of the former, who has been for some time, the 
leading French orthopedist. 

The writings of M. Guerin may be fairly criticised 
both for the wordiness and obscurity of their style, and 
for their unnecessary bulk ; but it does not appear that 
we have any right to question the accuracy of their 
statements. On the contrary, we may infer from the 
late report of the committee appointed by the Academy 
of Medicine to investigate this point, that there is no 
ground for supposing the evidence in any way warped 
or misrepresented. 

It is possible that M. Guerin has availed himself of 
the suggestions of previous writers ; that in common 
with other specialists, he has over-estimated the impor- 
tance and the efficacy of his art ; that he has been in- 



Vlll PREFACE. 

discreet in its application, and that " the division of 
forty-two tendons, muscles, &c, upon the same sub- 
ject," was an audacious undertaking, rather than " a re- 
markable achievement ;" but it should not be forgotten 
that the scientific acquirements and practical skill of 
this orthopedist are undisputed ; that he is the author 
of valuable discoveries, confirmed as such by the Acad- 
emy of Medicine, and that, much as he may be indebted 
to previous writers, the account has at least been squared, 
by the compensating drafts of those who have followed 
him. 

The article upon Strabismus, the first of this disser- 
tation, is somewhat disproportioned in length to the 
subsequent chapters. The materials were original- 
ly collected without the intention of incorporating 
them into this work. In allowing them to retain their 
present extent, I was decided mainly by the fact, that 
no complete treatise upon this subject had appeared 
upon this side of the water. The same is true of the 
chapter on Stammering, the operation for which is now 
a matter of history, a curious instance of the indiscreet 
zeal of some of the noted continental surgeons. 



CONTENTS. 



Dissertation, . . j .1 

Strabismus, . 3 

Anatomical Considerations, 4 

Movements of the Eye, ...... 7 

Functions of Muscles, . 8 

Causes of Strabismus, ...... 10 

Muscular Paralysis, . . : . . . .13 

Double Strabismus, ....... 16 

Anatomical Peculiarities, „ 17 

Age, ......... 17 

Operations, 18 

Appreciation of Different Methods, .... 27 

Exuberant Granulations, ...... 35 

Subsequent Treatment of the Eye, .... 35 

Do. do. of the Deformity, ... 38 

Bad Results of the Operation, 39 

Cicatrization of Parts, 41 

Dimness of Vision, i . 41 

Myopy, 42 

Diplopy, 44 

Kopiopy, ........ 44 

Nystagmus, 46 

Statistics, 45 

Stammering, 47 

General Remarks, 48 



CONTENTS. 



Analysis of Articulate Sounds, 
Operation of Dieffenbach, . 
French Operation, 
Accidents after the Operation, . 
Appreciation of the Different Methods, 
Statistics, 



Tenotomy, ... 

Subcutaneous Cicatrization of Divided Tendons, 
General Characters of Deformity, 
Contraction and Retraction, ; 

Pathological Transformations, .... 

Instruments and Manual of the Operation, . 
Hemorrhage, ....... 

Mechanical Treatment, ..... 

Club -Foot, . . 81 

Causes, ' . 81 

Retraction, . . . . ... . .84 



50 
54 
57 
60 
63 
67 

69 
71 

74 
74 
75 
77 
78 
79 



Varieties, 

Nomenclature, . 

Equinus, . = .... 

Varus, ....... 

Valgus, 

Talus, ...... 

Treatment without Section of Tendons, 
Contraction and Retraction, . 
Section of Tendons, .... 

Re-division of Tendons, 
Mechanical Treatment, 

Machines, 106 

Treatment of Equinus, . 

Varus, . 

Valgus, . 

Talus, . 
General Remarks, . 



84 
85 
86 
88 
91 
93 
93 
96 
97 
103 
103 



Torticollis, .... 
Causes, .... 

Retraction, • 
Symptoms, 

Sterno-Cleido-Mastoid Muscle, 
Vertebral Column, . 



106 
108 
110 
110 

111 

112 
112 
114 
115 
115 
116 



CONTENTS. XI 

Treatment without Section, . . . . .117 

Age, . . 118 

Section of Sterno-Cleido-Mastoid Muscle, . . .118 

Section of other Muscles, ...... 123 

Mechanical Treatment, 123 

False Anchylosis of the Knee-Joint, . . . 127 

Causes, 128 

Retraction, ....*•• • 128 

Pathological alteration of the Tissues and their Conse- 
quences, ........ 129 

Diagnosis of the Different Organic Lesions, . . 131 

Treatment, 134 

Results, 134 

Medical Treatment, 138 

Surgical Treatment, 139 

Treatment without Tenotomy, . . . . 139 

Section of Tendons, . . .... 140 

Mechanical Treatment in the Chronic Form, . . 144 

Sudden Extension, ....... 144 

Slowly Progressive Extension, .... 146 

Restoration of Mobility, .;.... 148 

Mechanical Treatment with Tenotomy during Inflam- 
mation, . . 148 

Ricketty Knees, . 152 

Medical Treatment, 152 

Surgical Treatment, 153 

Permanent Flexion of the Hip-Joint, .... 155 

Operation, . . 156 

Anchylosis, .......... 157 

Lateral Curvature of the Spine, .... 159 

Causes, 162 

Cause of the Congenital Variety, .... 163 

Muscular Retraction, 164 

Vertebrae, 165 

Thorax, * . . .166 

Causes of Non-Congenital Variety, .... 167 

Curvature and Torsion, ...... 168 

Gibbosity, ........ 170 

Curves — their Position and Mechanism, . . .170 



Xll CONTENTS. 

Twelfth Dorsal Vertebra, 171 

Curves of Compensation, ....;. 171 

Treatment, 173 

Gymnastic Exercises, . . . . . . . 174 

Surgical Treatment, 175 

Operation, 176 

Mechanical Treatment, ...... 177 

Portable Apparatus, . . . . . . . 177 

Parallel Extension, . 179 

Sigmoid Extension, .180 

Contraction of the Hand and Fingers, . . . 183 

Causes, 183 

Operation — Its Results, 185 

Propriety of Section, ....... 186 

Mechanical Treatment, 187 

Congenital Dislocations, . .... 188 

Causes, . ........ 188 

Locality and Progress, . . . . - . ' • 189 

Conditions of the Muscles and Soft Parts, . . . 190 

Fibrous and Fatty Transformations, &c- • » . 190 
Alterations of Articulations, . . . . .191 

Indications of Reducibility, . . • • . 192 

Alterations of Parts in the Neighborhood of Luxation, 194 

Indications for Reduction, 195 

Means of Preparing for, Effecting, and Consolidating 

Reduction, 195 

Recent and Chronic Dislocations, .... 197 

Section os Muscles in Locked-Jaw, . . . • 199 

Subcutaneous Section of the Orbicular Muscles, . 201 

Appendix, . • . . 203 

Casting in Plaster, 203 



DISSERTATION. 



It is obviously difficult to procure the evidence 
upon which a direct answer to the question pro- 
posed by the Committee should be based. The 
subject is comparatively new, and demands farther 
investigation. Among its different departments, it 
is easy to show why the present operation for 
stammering should be proscribed ; but it is not 
easy to indicate the cases which require a sec- 
tion of the muscles of the back, or of the ten- 
dons of the hands and fingers. These questions can 
be decided only by a careful analysis of a large 
number of cases, with reference to the pathological 
conditions of the subject, and the results of differ- 



2 DISSERTATION. 

ent methods of treatment. They have not been 
settled by those most conversant with this branch 
of Surgery, and demand opportunities which are 
probably afforded only by the larger European 
institutions. 

It is believed that the general intention of the 
committee will be fulfilled, by an attempt to cover 
the ground now occupied by Orthopedic Surgery. 



STRABISMUS. 



But few years have elapsed since the operation 
for Strabismus was announced, under circumstan- 
ces of considerable interest. It proposed the relief 
of an obvious and frequent deformity, with little 
pain or hazard to the patient, and, at the same 
time, promised to the surgeon the notoriety which 
attends a new and successful operation. Thus re- 
commended, it rapidly gained ground, and was per- 
formed many hundred times in Europe and in this 
country, not only by competent surgeons, but by 
operators, who either were not qualified to investi- 
gate the lesion in a scientific view, or whose inter- 
est it was to furnish incorrect or partial statements 
of their results. 

Of the memoirs upon this^subject, many offer a 
limited series of observations, inadequate for pur- 



4 STRABISMUS. 

poses of induction ; others are manifestly inexact ; 
and a still greater number are controversial essays ; 
adapted to advance a particular method, or its ad- 
vocate, at the expense of others. The following 
details have been drawn from the few more 
authentic papers which have recently appeared. 

ANATOMICAL CONSIDERATIONS. 

The ball of the eye offers little worthy to be 
noted in connection with this operation. The 
Sclerotic is a dense, resisting coat, which may be 
freely denuded with probe pointed instruments 
without risk of perforation, or other mechanical 
injury ; neither does it readily become inflamed. 

Vessels. A case of alarming hemorrhage from 
the operation, has been published in the English 
journals, and seems to have been the result of a 
decided hemorrhagic diathesis in the patient, a 
child of eleven years of age. The hemorrhage 
was arrested after the transfusion of several ounces 
of blood from the arm of a healthy adult. In a 
normal condition of the circulating system, the ar- 
teries of the orbit are not of a size to occasion dan- 
ger or inconvenience from hemorrhage, while the 
veins in the region of the ethmoid bone are easily 
avoided. 

Nerves. Tt seems superfluous to suggest that 
the optic nerve, inserted somewhat nearer the 
inner than the outer angle of the eye, may be 
wounded by a deep and careless dissection upon 



ANATOMICAL CONSIDERATIONS. 5 

the nasal aspect of the globe. An instance of its 
actual division in this way, has, however, been re- 
ported. The internal, superior, and inferior recti 
muscles, and the inferior oblique, are supplied by 
different branches of the motor communis or third 
pair ; while the superior oblique and external rectus 
muscle, each appropriating a separate nerve, are 
supplied by the fourth and sixth pairs respectively. 
No ill effect results from the section of the branches 
of these nerves at the point where the muscle is 
usually divided. 

Muscles. The four recti and two oblique mus- 
cles of the globe, are the chief agents in the pro- 
duction of Strabismus. The vivid red of the mus- 
cular fibre can, in most cases, be detected at the 
bottom of the incision, while the fan-like expansion 
of its tendinous insertions is often invisible among 
the surrounding tissues. The anterior tendinous 
fibres of the four recti muscles, are inserted at the 
distance of two or three lines from the cornea, 
while other fibres attach themselves to the sclerotic 
a line or two behind ; so that the whole some- 
what resembles in form the adhering tail of a leech, 
to which it has been aptly compared. 

The superior oblique muscle springs from the 
fibrous sheath of the optic nerve, traverses the pul- 
ley at the upper and internal angle of the orbit, 
and turning backwards and outwards, joins the 
sclerotic beneath the superior rectus muscle and a 
little behind its insertion. 

The inferior oblique leaves the superior maxil- 



6 STRABISMUS. 

lary bone in the neighborhood of the lachrymal sac, 
and retreating a little, winds outwards round the 
globe of the eye, to be inserted upon its upper and 
external surface. 

Aponeuroses. Much attention has been directed 
of late years to this part of the anatomy of the eye, 
especially by Guerin, Velpeau and Bonnet (de 
Lyons). Their researches have demonstrated two 
principal fibrous expansions. 

The first, which lines the periosteum of the orbit, 
retreats upon the optic nerve behind, and being 
continued forward upon the eye-lids to their free 
edges, envelopes in this manner the whole contents 
of the bony orbit. 

The second is in contact with the sclerotic, which 
it covers and protects as it were, from the surround- 
ing adipose matter. In front, it is reflected upon 
the internal surface of the conjunctiva, which it 
lines to its insertion at the edge of the lids, where 
it unites with the aponeurosis of the bony orbit. 
Behind, it is prolonged upon the optic nerve, where 
it again joins the orbitar aponeurosis, with which 
it forms a shut sac, from which the globe of the eye 
is excluded, much as the intestine is excluded from 
the cavity of the peritoneum. This sac is traversed 
by the muscles, each of which, as it enters the 
cavity, borrows from it a fibrous envelope, which 
is reinserted at its point of exit. A tube is thus 
formed, which gives passage to the muscle with- 
out affecting the integrity of the sac. 

It will be remembered that these aponeuroses are 



MOVEMENTS OF THE EYE. 7 

chiefly noted for the role which different writers 
have assigned them in ocular deformity, and the im- 
pediment they are supposed to offer to the various 
steps of the operation. They have also a certain 
influence in the normal movements of the eye, to 
be hereafter examined. 

MOVEMENTS OF THE EYE. 

Muscles. The action of the recti muscles upon 
the globe is easily understood ; and I am not aware 
of any difference of opinion upon this point. If a 
single muscle acts, the pupil turns towards it, upon 
a vertical or horizontal line. If two juxtaposed 
muscles contract, the pupil moves obliquely in the 
diagonal of the forces thus applied. Less is known 
of the action of the oblique muscles, and while 
eminent writers have cited a variety of evidence in 
support of their different theories upon this point, 
the contradictory character of their opinions leads 
us to doubt their accuracy. That certain forms of 
strabismus are said to require a division of these 
muscles, is a sufficient apology for a somewhat 
detailed examination of the movements attributed 
to them. 

The superior oblique draws the point of its scle- 
rotic insertion towards the cartilaginous pulley, 
while the action of the inferior oblique is direct. 

Cruvelhier ascribes to the superior oblique a sim- 
ple action of rotation of the ocular globe upon its 
antero-posterior diameter, the eye being at the same 



8 STRABISMUS. 

time slightly carried forward in the orbit. To the 
inferior oblique, he attributes a similar rotation in 
an opposite direction. 

Velpeau supposes that the superior oblique carries 
the eye inwards and downwards ; while at other 
times it rather aids the external rectus and inferior 
oblique in external strabismus. 

Charles Bell has termed the superior oblique a 
respiratory nerve, from its supposed influence in 
raising the eye in the expression of certain emo- 
tions ; as in sighing. In experiments upon the 
dead subject, he found the eye turned downward 
and outward by traction upon this muscle. In sup- 
posing that in life it antagonizes the inferior oblique 
muscle, he suggests that its involuntary relaxation 
in certain expressions gives an opportunity for the 
action of the latter muscle, which then rolls the 
pupil upwards. 

A later and more plausible theory of Guerin, 1 
and Skolaski? is supported by a number of patholo- 
gical observations, and can easily be tested. 

Examine the eyes of a person at a convenient 
distance, and draw imaginary horizontal lines 
through spots upon the conjunctiva. Let the head 
now be laterally inclined towards the shoulder, and 
it will be seen that the imaginary lines continue hor- 
izontal and parallel with the floor or ceiling of the 
apartment, although their position in relation to the 
lids be changed ; in other words, the eye tends, by 

1 Communication a Tlnstitut. Aout 18-40. 

2 Mem. Addresse a la Societe de Medec. de Gand. 1840. 



MOVEMENTS OF THE EYE. V 

a rotation upon its antero-posterior axis, to retain 
its relative vertical position. Whatever be the util- 
ity of such an involuntary movement, it must be 
allowed that it belongs to the oblique muscles, as 
supposed by these physiologists ; although it attri- 
butes to the inferior oblique branch of the third 
pair of nerves, the power of producing involuntary 
action. 

Aponeuroses. The aponeuroses are said to pos- 
sess a certain influence upon the movements of the 
eye. In the lateral movements of the ball, the angles 
of the lids enlarge at the approach of the pupil ; and 
certain writers have supposed this action to be due 
to a simple traction of that portion of the aponeuro- 
sis of the globe, which is prolonged to the free edge 
of the lids. A permanent displacement of the ball 
would then occasion permanent traction of the lids. 

But this explanation is open to objection. Were 
the harmony of action between the lids and the 
globe due to a purely mechanical influence of the 
fibrous tissues, it should follow, that when the pupil 
is buried beneath the roof of the orbit, both lids 
should be equally elevated by their respective apon- 
euroses. The pupil rolls thus upwards in the in- 
voluntary motions described by Charles Bell, a fact 
verified by placing the finger upon the lids while 
they are forcibly shut. It is then observed that 
while the pupil rises involuntarily, the upper eye-lid 
falls ; an antagonizing action directly opposed to 
the upward traction of the ball upon the upper lid. 
The lower lid seems to be more directly attached 

2 



10 STRABISMUS. 

to the globe. It follows the elevated pupil, and 
never antagonizes the superior lid so well as when 
the eye is rolled up beneath the orbit. 

The importance of these aponeuroses in their 
healthy condition seems to have been exaggerated. 
It is, however, easy to suppose, that bands of con- 
densed cellular tissue might attach themselves to 
various parts of the orbit and globe, and tend to im- 
pede the free motions of the eye, especially were 
the globe retained by muscular contraction or other- 
wise, in a given position, for a length of time. 

CAUSES OF STRABISMUS. 

Strabismus is characterized by a want of har- 
mony in the action of the eyes. The internal recti 
muscles alone possess the power of producing a vol- 
untary strabismus ; which is then an exaggeration 
of the convergent action which directs both eyes 
towards a single object. 

The duration of strabismus varies with its excit- 
ing causes. 

One variety of the deformity depends upon a 
transient spasmodic action of the muscles. It is 
observed in many individuals while talking ; and is 
sometimes of momentary duration. Different excit- 
ing causes of this variety have been noticed. A 
moment of anger ; an elevated temperature ; a 
current of air upon the forehead ; or any cause 
which acts upon the nervous system. Temporary 
strabismus has been known to precede the cata- 



CAUSES. 1 1 

menial discharge, and has been observed in infants 
immediately before the development of dentition. 

Another variety accompanies apoplexy, or other 
grave lesions of the brain ; while a third class re- 
sults from tumors in the soft, or bony tissues of the 
orbit ; in which cases the deformity is symptom- 
atic, and directs attention to the more serious af- 
fection. 

There are, however, certain forms of strabismus, 
less immediately connected with important organic 
lesion, which depend upon the physiological condi- 
tions of the surrounding tissues. In these cases 
the affection may originate in the muscles, or the 
nerves which supply them ; or result from a de- 
rangement in that part of the machinery of the eye, 
which is directly concerned in the sense of vision. 

I. Muscular Contraction. While the operation 
was yet new in England, Sir Astley Cooper 
remarked to the writer of this paper, that he 
believed it impossible that it should generally 
succeed ; that while the correction of the deform- 
ity of a limb, was mainly due to its treatment 
after the operation, the nature of the eye would 
forbid the application of an efficient orthopedic 
apparatus. Strabismus has been elsewhere term- 
ed the club-foot of the eye ; but the condition of 
the parts is not such as to warrant the comparison. 
If a club-foot be examined, the retraction is found 
to be firm and permanent. The foot yields but 
little to the application of a considerable force. 
But if in a common case of ocular deformity the 



12 STRABISMUS. 

sound eye be closed, it will be found at the end of 
a certain time, that the pupil of the affected eye 
emerges from the angle of the lids, and advances 
to take its place in the centre of the orbit, while 
the sound eye is in its turn everted. In the former 
case the muscle has lost its power of elonga- 
tion ; it often undergoes a transformation which 
assimilates its substance to that of a fibrous tis- 
sue. In the eye, on the other hand, the muscle re- 
tains its anatomical structure, such a transforma- 
tion being very rare. In four hundred and twenty- 
two cases operated upon by Phillips, the fibrous 
transformation occurred three times ; while in more 
than five hundred patients, two cases only were ob- 
served of fatty transformation. 

What then is the condition of the muscle in the 
majority of cases ? Accumulated testimony seems to 
warrant the assertion, that the muscle is in a condi- 
tion of permanent but active contraction ; an expla- 
nation more readily received, when it is remembered 
that a great number of cases are sudden in their ac- 
cess, and date from the convulsions of infancy. 

2. Optic Strabismus is a term applied by M. 
Guerin to the deviation which sometimes follows 
distortion of the pupil, or spots upon the cornea in 
the axis of vision. As the rays of light are thus 
hindered from reaching the retina in a direct line, the 
eye deviates from a central position, in such a way as 
to present a transparent portion of the cornea, or the 
pupillary aperture, directly to the object. Although 
such cases are not uncommon, every surgeon has 



CAUSES. 13 

observed central opacities of the cornea without 
ocular deviation. M. Guerin supposes that this 
sort of distortion forbids operation. On the other 
hand 5 M. Velpeau affirms, that the lesion presents 
no greater tendency to reappear in these cases than 
in others ; and in balancing the amount of vision 
acquired by the deformity, against the personal at- 
tractions lost by it, he considerately submits the 
question to the vanity of the patient. Surgeons 
having thus acquired the power of correcting stra- 
bismus at the expense of the sight, it obviously re- 
mained for some ingenious oculist to undo the 
operation by reversing the process ; to restore the 
vision by producing a squint. This has been done 
by M. Cunier. He proposes * in cases of central 
opacity of the cornea, to divide one or more muscles 
of the eye, so as to determine a strabismus, which 
shall put the pupil in relation with that portion of 
the cornea which remains transparent, and thus 
permit the light to arrive at the bottom of the eye. 
3. Strabismus from Muscular Paralysis. The 
affection which gives rise to this form of strabismus, 
has received much attention of late years, from 
ophthalmic surgeons, and especially from M. Sichel. 
Its effect is analogous to the distortion observed in 
the extremities, when the paralysis of certain mus- 
cles is followed by the unopposed retraction of their 
antagonists. It occurs in certain cases of a paralytic 
affection of one or several of the muscular fasciculi. 

1 Lettre a 1' Acad, des Sciences. 1841. 



14 STRABISMUS. 

If the external rectus be alone involved, the eye de- 
viates to the side of the nose. If the internal rectus 
be affected, external strabismus is the result ; and 
the eye turns up or down, as the inferior or superior 
straight muscles cease to act upon it. 

An affection of the third pair of nerves sometimes 
occasions paralysis of the three muscles which it 
supplies, and the external rectus alone retains its 
power. 

Distortion of this sort, is distinguished from com- 
mon strabismus, by the inability of the patient to 
direct the eye towards the affected side, when the 
other eye is closed. The deviation is sometimes 
slight, and the eye merely refuses to follow its 
companion in certain directions, while otherwise 
it moves freely. It is less easy to distinguish a 
paralysis of several muscles, from that form of stra- 
bismus which results from adhesion of the surround- 
ing tissues, and immobility of the eyeball. A de- 
gree of motion, however, exists in most cases, and 
were there none, the former might be distinguished 
by its capability of passive or forced motion, which 
the fixed immobility of the other forbids. 

These varieties of strabismus have been subject- 
ed to operation. It is, however, evident that 
remedies should be directed to the original lesion, 
so long as they promise a chance of relief. If the 
case assume a chronic form beyond aid from reme- 
dial agents, an operation may be resorted to, with 
a view of restoring the eye to the centre of the 
lids. It is sometimes accompanied with advantage 



CAUSES. 15 

to the sight, but is more frequently an operation 
c de complaisance. 1 * 

Paralysis of the oblique muscles is more difficult 
of diagnosis. Two cases, probably of this affec- 
tion, reported by M. Skolaski, 1 seem to confirm 
the supposition already alluded to, that these mus- 
cles exercise an action of rotation upon the eyeball. 
In both these interesting cases, the eye refused to 
imitate the rotatory motion of its fellow, when the 
head was inclined towards the shoulder, and in 
this position diplopy ensued. The images were 
superposed, and mutually receded in a vertical 
direction, as the head was inclined that of the 
stationary eye being always below. 

The various duties assigned by different ob- 
servers to these muscles, have been enumerated at 
some length, in another part of this paper ; and it 
has been seen that the most contradictory opinions 
have been entertained of their real purpose. It can- 
not, therefore, be shown what variety of distortion 
would result from their permanent contraction. In 
fact, they have often been divided for strabismus ; 
but the results of the few trustworthy observations 
upon this point are so widely opposed, that their 
section must be regarded, at present, as purely ex- 
perimental. 

4. Strabismus from Amaurosis. Functional, 
or other lesion of the optic nerve, has been con- 
sidered both as a cause and an effect of ocular dis- 

3 Longet. Anat. et Phys. du systemo nerveux. Paris, 1812. T. ii. 
p. 396. (Sec page Qth.) 



16 STRABISMUS. 

tortion. It is undoubtedly true that amaurotic eyes 
are not exempt from the various distortions which 
affect these organs. If amaurosis is a cause of stra- 
bismus, restored vision will probably rectify the de- 
viation. The effect of the operation upon amau- 
rosis, will be again adverted to. 

DOUBLE STRABISMUS. 

In most cases of simple strabismus, if the patient 
be directed to regard a distant object, he does so 
with the sound eye, while the affected eye squints. 
The sight of the deviating organ is often imperfect. 
It is not uncommon to meet with patients who 
have acquired a habit of using the sound eye for 
more remote objects, w 7 hile the squinting and often 
near-sighted eye is reserved for reading, and view- 
ing objects close at hand ; and a singular effect is 
produced by their ability to advance either pupil at 
will. But it sometimes happens, that both eyes 
present a slight deviation. In such cases, the ope- 
ration should be confined to that which presents the 
greatest distortion. A month should be allowed to 
elapse, before operating upon the second ; during 
which time, in a majority of cases, the movements 
of the two eyes become parallel. 

Velpeau allows it to be difficult to distinguish 
cases of really double strabismus, from those which 
are so only in appearance, and which demand a 
single operation to correct an apparent double de- 
formity. M. Phillips operates upon both organs, 



AGE. 17 

only when the deviation in the two eyes is uniform ; 
but then only at an interval of a month or more. 

ANATOMICAL PECULIARITIES. 

Adhesions of the Globe give rise to perma- 
nent strabismus, distinguished by its incapability 
of passive or forced motion. Such cases result 
from wounds and deep-seated inflammation of the 
orbit. Velpeau alludes to cases not referable to 
such conditions, in which the muscle adhered to 
the sclerotic as far as the posterior part of the eye. 
The operation requires extended dissection, and is 
liable to be followed by re-adhesion. Successful 
results have, nevertheless, been reported by Velpeau 
and others. 

Triple Insertion. The internal and superior recti 
muscles are, in rare instances, divided into two 
or three fasciculi, at their then fanlike insertions, 
either of which may aid in producing a deviation. 

Fibrous and fatty Transformations of the muscles 
are rare, and have been elsewhere alluded to. 

AGE. 

Neither infancy nor old age have been exempt- 
ed from this oft repeated operation. In young in- 
fants, the deformity sometimes disappears spon- 
taneously, while old people rarely care to be re- 
lieved of it. After the age of three or four years, 
the chances of success are greater in proportion to 
the youth of the patient. M. Velpeau asserts, that 



1 8 STRABISMUS. 

the tissues require a more extended division in old 
people. 

OPERATION. 

Though definitely indicated by Stromeyer, in 
1838, and performed upon the dead body by that 
surgeon, the operation for Strabismus was first ap- 
plied to the living subject in modern times, by 
DiefTenbach, the 26th October, 1839. 

It is probable that a similar operation was 
practised many years ago. The following curious 
advertisement of an English oculist, named Taylor, 
who lived in the last century, is to be found in the 
Mercure de France, annee 1737, juin, p. 1180. 
" Doctor Taylor, Oculist of the King of Great 
Britain, has recently arrived at the Hotel de Lon- 
dres, rue Dauphine, Paris, where he proposes to 
stay till the beginning of July, after which he will 
leave for Spain. He begs us to publish the dis- 
coveries he has made to restore squinting eyes by 
a rapid operation, almost without pain, and without 
fear of any accident." 

1 M. Cunier refers to this singular phrase in the 
dissertation of Verheyden, in 1767, " Strabones per- 
multos ferro sanatos apud Anglicos vidi." 

Whatever be inferred from these passages, the 
operation was unknown to surgeons at large, till 
late years. 

1 Re suppl. aux. Ann. d'Oculist. Fev. 20, 1841. 



OPERATION. ] 9 

M. Carron du Villards pretends to have thought 
of it in 1838. 

Dr. Ingalls, of Boston, Mass., is said * to have 
suggested it as far hack as 1812-13. 

Pauli, a surgeon of Landau, in 1839, was only 
prevented from attempting it by the indocility of his 
patient. But the first authentic operations upon 
the dead and living subject, belong to the surgeons 
of Hanover and Berlin. 

A few months sufficed to introduce this surgical 
novelty into England and France. I was present 
in Sept. 1840, at some of the earliest experiments 
made in London. The simplicity and safety of 
the operation soon became known, and the new 
ground was at once occupied by a host of explorers 
striving to identify themselves with its success. 
All were armed with peculiar and indispensible in- 
struments, with curious hooks and complicated 
scissors ; with knives studiously fashioned to differ 
from each other. The method continually varied ; 
and there were few surgeons who had not an 
operation of their own, distinguished by their name. 

The general principles of most of these differ- 
ent methods, are the same ; and I propose to ex- 
amine them under the three following heads. 

1. Those which resemble the operation of Stro- 
meyer and Dieffenbach, in which the conjunctiva is 
first divided. 

2. Those in which all the tissues are divided at 
once ; as in the method of Velpeau, 

1 Medical Examiner, Feb. 1841. 



20 STRABISMUS. 

3. The Subconjunctival method of Guerin. 

In every method, the aim of the operation is the 
division of the muscle, and it is of little real im- 
portance whether it be effected in one way or 
another. But there is hardly a surgeon or an ocu- 
list who has not suggested some superfluous modi- 
fication or complication of this simple manoeuvre ; 
and within a week I have observed in one of the 
journals, the re-invention of an instrument con- 
trived some two years since. In the words of Mr. 
Liston, " All this is for the use of those gentlemen 
practising surgery, who are deficient in dexterity, 
and for the benefit of the cutlers." A somewhat 
tedious examination of the more important methods, 
if it serve no other purpose, may tend to show that 
there is little new to be contrived, either in the in- 
struments or manual of this frequent operation. 

For greater convenience, the operation is, in gen- 
eral, described with reference to convergent strabis- 
mus of the right eye. 

Operation of Stromeyer. The sound eye be- 
ing covered, the patient is directed to turn the 
affected eye outward. A small double hook is 
implanted in the conjunctiva at the internal part 
of the globe, and confided to an aid. The fold of 
conjunctiva is then raised with forceps near this 
point, and divided vertically with a cataract knife ; 
after which the aid draws the eye outward, while the 
surgeon passes a small curved sound underneath 
the muscle, and divides it with the knife or curved 
scissors. 

It should be remembered, that in operating upon 



OPERATION. 21 

the dead subject, Stromejer was not compelled to 
confine the lids. 

DieffenbacWs Method is similar, but characteriz- 
ed by a greater complication of aids and instru- 
ments. The instruments are, the elevator of 
Pellier for the upper, and a double blunt hook with 
a long slender handle, for the lower lid. Two 
slender hooks to pierce and raise the fold of con- 
junctiva ; scissors curved on the flat, to divide the 
conjunctiva and the muscle. A blunt hook to insin- 
uate beneath the muscle, and finally, in refractory 
patients, a double short pronged hook, to pierce the 
sclerotic and confine the eye. Two assistants in gen- 
eral suffice. The patient is seated opposite the light, 
the head confined upon the chest of an aid. The sur- 
geon sits in front of the patient, without excluding 
the light, and passing the elevator beneath the upper 
lid, transfers it to his aid. The double hook depresses 
the lower lid, and is held by the second aid, who 
kneels. The fold of conjunctiva is now suspended 
between the two small hooks ; the first, at the in- 
ner angle, being confided to the first aid, while the 
second, near the cornea, is retained by the operator 
in his left hand. The fold is snipped with curved 
scissors, and the muscle exposed by dissection. The 
surgeon then abandons the scissors, introduces the 
blunt hook beneath the muscle, and, as a final step, 
divides it with the scissors. 

In some of his earlier operations, Dieffenbach 
excised a portion of the tendinous extremity of 
the divided muscle, but subsequently renounced 
this process. 



22 STRABISMUS. 

The Operation of Phillips, a pupil of DiefTen- 
bach, is nearly identical with this. 

Guthrie' } s Method. In the operations which I saw 
performed by Mr. Guthrie in Sept. 1840, the man- 
ual resembled that of Stromeyer. The lids be- 
ing confined by instruments, or by the finger of the 
operator and that of an aid, the sclerotic was 
transfixed by a double hook, and the ball everted. 
The conjunctiva being then raised upon a hook and 
opened, a slight dissection exposed the muscle. A 
curved director was now passed beneath the muscle, 
and served to guide a short, pointed, curved bis- 
toury to divide it. 

Methods of Ferral and Lucas. These differ little 
from that of DiefFenbach. In the former, the for- 
ceps are substituted for one of the hooks of the 
conjunctiva, and angular for curved scissors. 

Liston's Method. With a view of dispensing 
with one of his aids, this surgeon proposes to fax 
the eye and raise the conjunctival fold by a pair of 
spring toothed forceps, which, once attached to the 
conjunctiva near the inner angle, are left to them- 
selves, and by their weight confine the lower lid. 

The Methods of Roux and of Sedillot resemble 
that of Guthrie, in the use of the curved director. 
To fix the globe, M. Sedillot employs a hook with 
three branches, each furnished with a small sphere 
like a shot, at the distance of a line from its point, 
to prevent it from too deeply penetrating the scle- 
rotic. 

Baudens' Method. The lids being fixed as in 



OPERATION. 23 

DiefTenbach's operation, the surgeon transfixes with 
a strong, single hook, both the conjunctiva and the 
muscular attachment. The eye is then drawn out- 
wards, and the muscle rises in a plait or fold. 
Under this he inserts M. Baudens' knife and 
divides the mucous coat together with part of the 
muscle. The remainder of the muscle is raised 
with a blunt hook, edged upon its lesser curve, 
which thus severs its fibres. M. Baudens removes 
the tendinous insertion, and also trims the conjunc- 
tival edges, with a view to relieve the wound of 
filaments which might impede its union. 

The knife of M. Baudens (fig. 4) is about an 
inch in length, and a quarter of an inch wide at the 
base, and pointed. It is curved on the edge to 
about a quarter of a circle. It is also slightly curv- 
ed upon the flat, and the point is thus directed away 
from the globe of the eye, while the wedge shape 
of the blade enables it to cut its way out in tra- 
versing its length. It is evident that a different 
curve is required, for each eye. 

Method of Amussat. This diners little from 
those already cited, except in the blunt hook in- 
serted beneath the muscle. M. Amussat has con- 
trived an instrument consisting of two hooks lying 
side by side, and so adapted to each other, as to 
resemble a single one. These hooks are introduced 
between the muscle and the eye, opened, and the 
muscular fibres divided between them. M. Phil- 
lips asserts that the instrument was previously in- 
vented and rejected by Dieffenbach. 



24 STRABISMUS. 

Finally, M. Gairal has proposed a hook armed 
with a button and bent at right angles ; the dis- 
tance from the elbow to the button being four lines. 
This serves to designate the position of the tendon 
in measuring the distance between its insertion and 
the edge of the cornea. Introduced beneath the 
muscle, the arm of the instrument is sufficiently 
long to embrace the fibres in all then* width. 



2. OPERATION IN WHICH ALL THE TISSUES ARE DIVIDED 
AT ONCE. 

First Method of Velpeau. 1. The lids being 
held apart by instruments, a double hook is plung- 
ed in the sclerotic near the cornea, and the eye 
drawn outward. 

2. A strong single hook is thrust under the mus- 
cle near the angle, and a fold thus raised. 

3. With a small curved knife the entire fold is 
divided ; consisting of the muscular fibres, cellu- 
lar tissue, and the conjunctiva. 

M. Andrieux proposes to give the hook an edge 
upon its lesser curve, which would then cut its way 
out. 

Second Method of Velpeau. The lids are sep- 
arated by a self-adjusting speculum termed a ble- 
phareirgon (fig. 13), invented in England and mod- 
ified by M. Velpeau. With a strong pair of toothed 
forceps, the surgeon seizes the insertion of the 
tendon and everts the eye. With a similar pair 
which he afterwards abandons to an aid, he 



OPERATION. 25 

grasps the muscle and conjunctiva at the angle. 
He then divides the muscle and surrounding 
tissues near its middle, with a pair of curved or 
straight scissors, the blunt points of which are re- 
peatedly passed backwards and forwards upon the 
sclerotic, to plough up any accidental undivided 
fibres. A last stroke of the scissors excises the ten- 
dinous insertion, and its conjunctival covering, yet 
retained by the first pair of forceps. 

This operation, w T hich I have repeatedly seen per- 
formed by M. Velpeau, involves a free division of 
the tissues surrounding the retracted fibres. 

The teeth of forceps intended to grasp the tis- 
sues exterior to the sclerotic, should be slightly 
recurved, that their convexity may repel this 
membrane when pressed against it, while their 
approaching extremities pierce the tissues in im- 
mediate contact with it. 

M. Velpeau sometimes uses but one pair of for- 
ceps, and the operation then resembles that pro- 
posed by M. Daviers (d'Angers.) 

A sponge is often required during the operation, 
and a pair of slide forceps has been contrived to 
hold it, attached to the handle either of the knives 
or scissors, (fig. 4). 

3. SUBCONJUNCTIVAL METHOD. 

Applying to the eye, the principles of subcutane- 
ous operations, M. Guerin has adopted a process 



26 STRABISMUS. 

which, though somewhat complicated, deserves at- 
tention. 

The instruments in this operation are peculiar. 
A spear resembling a saddler's awl, whose greatest 
width is rather less than a quarter of an inch, an 
inch in length, and slightly curved upon the flat, 
that it may follow the ocular sphere, serves to 
pierce the mucous envelope. 

The shaft of the knife employed, is first bent to 
a right angle, and then rebent to its original direc- 
tion at the interval of about an inch (fig. 6, 7). 
Two elbows are thus formed, to one of which is 
attached a strong handle, while the blade at the 
other is an inch in length, and slightly convex on 
the edge. They allow the handle of the instru- 
ment to lie flat upon the cheek or forehead of the 
patient, while the blade is beneath the muscle to 
be divided, and perpendicular to its fibres. In 
other words, the bend in the shank of the knife, 
adapts it to the depression of the eye beneath the 
orbitar ridge. 

The manual is as follows, the patient lies upon 
a table, the head supported by a pillow, while the 
lids are confined by any of the common means. A 
double hook is plunged in the sclerotic, near the 
cornea, and when the eye is everted, abandoned to 
an aid. A fold of conjunctiva is now raised near 
the insertion of the tendon, with a hook, which the 
operator holds in his left hand, while with his right, 
the spear is carefully plunged to the depth of half 
an inch along the inner surface of the muscle, and 



OPERATION. 27 

then withdrawn. The operator then directs the 
blunted point of the knife towards the occiput, 
enters it at the aperture, and engages it beneath 
the muscle. As a second step, he depresses the 
handle upon the cheek, so that the blade lies 
across and beneath the muscle, while the shank 
of the knife, between its elbows, is engaged 
in the small conjunctival aperture. By a third 
manoeuvre, he turns towards the muscle the edge, 
which previously looked towards the occiput. 
Extracting the now useless hook from the conjunc- 
tiva, and taking in his left hand the sclerotic hook 
from the aid who has held it, he gently draws the 
eye outward, while with his right, he severs the 
muscle by a sawing motion of the knife. Its 
division is attended with a slight noise, audible at 
some distance. The surface of the eye is then ex- 
plored, by ploughing, as it were, its surface with the 
blunted point of the knife, and, thus any remaining 
fibres are divided. The instrument is withdrawn 
with a movement, the reverse of that by which it 
entered. 

Such is the operation in which I have often 
assisted M. Guerin. With a little manual dexterity, 
it is quite simple, and seldom occupies more than 
half a minute in its execution. 

APPRECIATION OF THE DIFFERENT METHODS. 

Before examining the details of the operation, it 
will be well to determine, as nearly as possible, the 






28 STRABISMUS. 

conditions most important to its success. At Paris, 
the early operations of MM. Roux, Sedillot, and 
others were eminently unsuccessful. Of ten cases 
reported by M. Velpeau, three only were radically 
cured of the deformity. When the method of Dief- 
fenbach was better understood, results were more 
favorable. Phillips, a pupil of this surgeon, ope- 
rating in the presence of Amussat, Baudens, and 
Lucien Boyer, obtained from them the avowal, 
" that they at last understood why, until then, they 
had only met with failure ; and they, with reason, 
referred the constant success of this operation, to 
M. Phillips' use of the blunt hook of Dieffenbach, 
in searching for the contracted muscle." 

It has been observed from what has preceded, 
that the chief use of the blunt hook, (crochet mousse, 
fig. 5,) is in searching for such undivided fila- 
ments, as may have escaped the first division of the 
muscle. Its blunt point is repeatedly passed back- 
wards and forwards, up and down, in a direction 
perpendicular to that of the muscular fibres ; and 
being urged against the sclerotic, it seldom fails to 
insinuate itself beneath the tissues nearest in con- 
tact with this membrane, which are then easily 
raised and divided. 

To a similar cause does M. Velpeau attribute his 
want of success, as will be inferred from his re- 
marks upon the operation of M. Phillips. " Seeing 
M. Phillips operate upon the dead subject, I at once 
understood that, in imitating him, we could hope to 
succeed, where we had completely failed. In fact, 



APPRECIATION OF THE DIFFERENT METHODS. 29 

observing that he divided the conjunctiva and all the 
tissues contained in the orbit, over a third at least 
of the surface of the globe of the eye, I perceived 
that among my patients, numerous layers destroyed 
by M. Phillips, must have remained in place. For 
my part, I had not dared, at first, so largely to de- 
nude the sclerotic, and to perform a dissection at 
once so extended and so profound, in the orbit. 
I avoided it with extreme care, and aimed espe- 
cially to confine the division of the conjunctiva and 
the other tissues, to a very small extent. The fear 
of seeing a phlegmonous inflammation establish 
itself in the orbit, did not permit me to go farther. 

" M. Phillips having affirmed that the conse- 
quence of such extensive denudations, of a division 
of the tissues, which had alarmed me upon the living 
subject, were extremely simple, and involved no 
serious accident ; and having soon after demonstrated 
the truth of his assertions in operating upon patients, 
our convictions were changed, and the question soon 
assumed a new phase." 

A complete division of the parts is then the 
great aim of the operation ; and it is safe to 
assert, that so long as any contracted filaments 
remain undivided, the success of the operation will 
be compromised. A partial section may in some 
instances suffice ; but at present, it is impossible to 
distinguish such cases, or to designate in the orbit 
the particular fibres concerned in the deformity. 

In dissecting perpendicularly down upon the 
sclerotic, we endanger its integrity. It is therefore 



30 STRABISMUS. 

necessary to interpose something between this 
membrane and the parts immediately in contact 
with it, by which they may be at once discovered 
and commanded. 

Now it is of little consequence whether this be 
effected by any of the numerous blunt hooks of 
different operators, by the probe pointed blade of 
curved or straight scissors, or by the rounded tip of 
M. Guerin's knife. The type and element of the 
instrument employed, is the blunted hook " crochet 
mousse" of DiefFenbach ; split longitudinally, and, 
attached to the crossed legs of the common forceps, 
it becomes the " crochet a ecartement " of DiefFen- 
bach and Amussat ; furnished with an edge upon 
its inner curvature, it is the " crochet bistouri " of 
Baudens ; and armed with a point, it is curved to 
the " crochet tranchant " of M. Andrieux, the 
" myotome a double courbure " of Baudens, and the 
common curved bistoury of other surgeons. It is 
also recognised in the blade of common curved 
scissors, which, in the hands of M. Velpeau, are 
straight ; while with M. Guerin, a knife attached to 
a crooked handle, answers the purpose. 

This step of the operation, I consider essential. 
The manual varies with the taste and habits of 
different surgeons ; but in every method, there is 
a blunted point thrust between the sclerotic and 
the kst undivided fibres. These being once dis- 
covered and elevated, are easily cut ; if raised upon 
the blunt hook^by a knife or scissors, or by the edge 
of the hook itself, if it have one. They are equally 



APPRECIATION OF THE DIFFERENT METHODS. 31 

well divided between the arms of the " crochet n 
of Amussat, by the twin blade of scissors, and 
finally, in the subcutaneous operation, by the edge 
of the tenotome. 

The other parts of the operation may be con- 
sidered in their order. The upper lid is, in gen- 
eral, better held by the common elevators, than by 
the finger of an assistant, though the latter is often 
sufficient. As in other operations upon the eye, the 
finger should be covered with cotton cloth, which 
absorbs the secretions, and maintains a better hold 
upon the lid. 

The lower lid may be confined by the forefinger 
of the operator's left hand, or by a double hook 
held by an aid. The forceps of M. Liston, attach- 
ed to the conjunctiva, are painful, and should only 
be employed when other assistance is not at hand. 

Snowden's blephareirgon appears to offer the 
most effectual and simple means of fixing the lids. 
The metallic band attached to it by Charriere, is 
unnecessary and inconvenient. The pain it occa- 
sions is slight, and the instrument makers are in 
the habit of applying it to their own eye, to show 
its efficiency. It might be rendered still less pain- 
ful, by a thread confining the arms, so as to prevent 
their diverging beyond a certain point. 

In most methods, the globe is commanded by a 
small double hook, which penetrates the sclerotic. 
It should be fixed by a sudden stroke, as in enter- 
ing a cataract needle. In case of failure with it, it is 
better to allow the wounded eye a short repose, as 



32 STRABISMUS. 

it often takes on a convulsive action, and is difficult 
to manage. This hook offers several advantages. 
While it controls the eye, it enables the surgeon to 
extend or relax the contracted tissue, as he se- 
cures and divides it. In the method of Dieffen- 
bach, the eye is less securely held by a flap of 
conjunctiva. 

The conjunctiva may be raised by hooks or tooth- 
ed forceps ; hooks being less painful ; forceps more 
secure. If the conjunctiva be alone transfixed, one 
or two hooks may be used, at the taste or discretion 
of the operator ; but when all the tissues are to be 
included in the fold, two forceps are evidently more 
effectual, though M. Velpeau occasionally employs 
but one. 

The incision of the conjunctiva, when near the 
cornea, is less liable to be followed by gaping of 
the lids and depression of the caruncula, than when 
near the angle of the eye. Though prolonged up- 
ward, it should terminate as near as possible to the 
lower edge of the muscle. The division of the 
aponeuroses downward, tends to induce a fall of the 
lower lid, and a consequent enlargement of the 
palpebral aperture. 

The length of the incision varies in different 
methods. While M. Phillips denudes a third or 
more of the ocular circumference, M. Guerin in- 
sists upon the advantage of a simple puncture of a 
size to admit the instrument. The truth lies be- 
tween these extremes, and it may be affirmed that 
an incision of about half an inch in length, suffices 



APPRECIATION OF THE DIFFERENT METHODS. 33 

in most cases for convenience of manipulation, and 
exposes the tissues to be divided. Its length ne- 
cessarily varies, and in general increases with the 
degree of the deviation. 

The cellular tissue once divided, and the red sub- 
stance of the muscle brought into view, or its posi- 
tion exposed, its fibres are raised by an instrument 
passed beneath it, in the manner before indicated. 
Premising that the blunt, hook requires least dex- 
terity, we may leave the instrument to be employed 
to the option of the surgeon. 

It is during this dissection, that the sponge is re- 
quired ; and is most convenient when attached to 
the handle of the cutting instrument. 

With the self-adjusting speculum, the operation 
of M. Velpeau, which embraces at once the tissue 
to be divided, is rapid and simple. The use of tooth- 
ed forceps is perhaps more painful than that of sin- 
gle hooks, but the whole method is more expeditious. 
I have repeatedly seen children undergo the opera- 
tion without manifesting pain. 

The removal of the end of the divided tendon is 
of doubtful efficacy. Adopted and rejected by Dief- 
fenbach, it is now practised by Velpeau, and by 
Phillips, while it is not essential to success. It is 
affirmed by these operators, that in precluding the 
possibility of union by first intention, the excision 
of the tendon reduces the chance of a return of 
the deformity. Phillips asserts that it never pro- 
duces accident, is not painful, and diminishes the 
quantity of exuberant granulations. 



34 STRABISMUS. 

The subconjunctival method of M. Guerin has 
been much decried. Its results, of which 1 have 
seen many, have appeared to me quite as success- 
ful as those of other methods, although I have no 
statistics upon this point. The manual dexterity 
requisite for its performance, has prevented its gen- 
eral adoption, and has probably interfered with its 
success in other hands than those of its inventor. 
Nevertheless, it has often proved efficient among 
skilful operators. It may be mentioned that Dr. 
Cabot of Boston, obtained excellent results from 
this method in Yucatan. The sclerotic surface 
should be carefully explored for undivided fibres, 
while the globe is rolled inward with the sclerotic 
hook, and the fibres thus relaxed. When the knife 
penetrates beneath them, they are extended across 
its edge, and severed. This method is often follow- 
ed by much ecchymosis, which is afterwards ab- 
sorbed. On the other hand, the free incision of 
the common method, is soon occupied by a bunch 
of fungous granulations, from which the narrow 
puncture of Guerin's operation is exempted. 

The matter may be thus summed up. 

1. The retracted filaments are to be completely 
divided. 

2. They are best detected with a blunt hook, 
or analogous instrument, insinuated beneath them. 

3. The other steps of the operation, are dictated 
by the inclination or habits of the surgeon. 

4. The simplest method is that of Velpeau. 



SUBSEQUENT TREATMENT. 35 



SUBSEQUENT TREATMENT. 

It will be readily conceived, that the treatment 
should bear some proportion to the extent of the 
incision and of the inflammation. In many cases, 
the patient continues his ordinary avocations with- 
out inconvenience ; while in some rare instances, a 
violent inflammatory action ensues. In general, 
compresses wet with cool water suffice as an im- 
mediate application to the eye. In two days, warm 
emollient lotions may be substituted, and at the end 
of three or four days, a few drops of some mild 
astringent collyrium may be instilled day and night 
into the angle. Attention being paid to cleanli- 
ness, it is rare that more violent remedies are called 
for, and the organ, if carefully watched, may be 
sometimes left to itself. 

If the inflammation tends to gain the cornea, 
leeches, or a cathartic are indicated ; in short, ordi- 
nary remedies are to be proportioned to the violence 
of the symptoms. Sometimes a few hanging fila- 
ments of the conjunctiva serve to keep up irritation, 
and require excision. 

Exuberant Granulations. A few days after the 
operation, if the incision has been large, the mucous 
membrane presents a number of small elevated pap- 
ules, somewhat resembling bubbles of air. Insen- 
sibly increasing in size, if kept wet with cold com- 
presses, they unite, become red and gorged with 
blood, and tend to excite a suppurative action of 
the adjacent surfaces. If the cold application be 



36 STRABISMUS. 

now discontinued, the excrescence becomes round- 
ed, smooth, shining, of a pearly color, and finally 
pediculated at base, when it may be snipped off 
without inconvenience. 

When not treated by wet compresses, the granu- 
lations sometimes refuse to unite. Then they re- 
quire to be excised separately, often with con- 
siderable hemorrhage, and are liable to be repro- 
duced. 

Cauterization, more painful and prolonged, is 
sometimes followed by cicatrices, with more or less 
retraction of the tissues. 

THE DEFORMITY AFTER OPERATION WITH ITS SUBSE- 
QUENT TREATMENT. 

In a large proportion of cases, when the opera- 
tion is well performed, the deviation is at once cor- 
rected ; and though the eye may be unable to 
move in the direction of the divided muscle, the 
pupil assumes a position in the centre of the pal- 
pebral aperture. But this is not a constant nor 
always a permanent result. 

In certain cases, the strabismus though less 
marked, is still perceptible. The sclerotic has been 
laid bare in the region of the retracted muscle, but 
the eye still deviates in that direction, and farther 
treatment is required to correct the deformity. 
Various methods have been devised for this pur- 
pose. 

Division of other Muscles. It has been shown 



THE DEFORMITY AFTER OPERATION. 37 

that the division of the oblique muscles, is uncer- 
tain in its results. 

Phillips divides the superior oblique, when with 
strabismus, the cornea is convex, and the eye 
salient and near-sighted. M. Velpeau has never 
divided it, and states that he knows no authentic 
and conclusive fact in favor of its section. 

Equally experimental is the division of certain 
fibres of the neighboring recti muscles. M. Vel- 
peau proposes to sever the inner fibres of the 
superior or inferior straight muscles, in convergent 
strabismus, and cites successful cases of these sup- 
plementary sections. It should be remembered, 
that while it multiplies chances of success, a free 
dissection exposes the patient to a variety of 
serious accidents. It is not unfrequently followed 
by exophthalmy, divergent strabismus, or fixed ad- 
hesion of the globe, and is for this reason rarely 
justifiable. 

Loop of Thread. Dieffenbach seizes with forceps, 
a fold of conjunctiva, with its subjacent cellular 
and fibrous tissues, and passes through it a thread, 
which is subsequently made fast to the nose, brow, 
or ear of the patient. The eye is thus retained 
in a normal position during four or five days, at the 
end of which time the thread cuts its way out. 
This method is, for obvious reasons, difficult of appli- 
cation. 

Compression. The convexity of the cornea 
affords a point of resistance, by which the ball may 
be in some sort fixed. The lids should be closed, 



38 STRABISMUS. 

and a small, soft, globular compress placed at the an- 
gle from which the pupil is to be expelled. It is re- 
tained in place by a bandage around the head, 
which is made to exert a slight degree of com- 
pression at that point. 

It should be mentioned that an unskilful applica- 
tion of this bandage in the service of M. Velpeau, 
was followed by phlegmonous erysipelas and de- 
struction of the eye. v 

Spectacles. An advantageous method frequently 
employed by M. Guerin, consists of glasses, upon 
which paper is pasted, so as to obstruct vision, ex- 
cept at a point distant from the divided muscle. 
The pupil seeks the light, and the eye is thus kept 
in a favorable position. 

It often suffices to cover the sound eye, and thus 
force the patient to exercise the other. 

Lastly, a slight deviation not unfrequently disap- 
pears, without care on the part of the surgeon. 

In another class of operated patients, the devia- 
tion, corrected at the time, tends to return, at an in- 
terval of from one to four weeks after the operation. 
The same methods are here advisable ; especially 
that of bandaging the sound eye, and the use of 
covered glasses, or a bit of paste-board bridging 
across the orbit, and permitting vision only at the 
point required. 

A Second Operation. If the wound has healed, 
it becomes a question if a second operation is indi- 
cated. For results of such cases, the reader is re- 
ferred to the numerous papers of writers upon the 



THE DEFORMITY AFTER OPERATION. 39 

subject, each of whom emulates the other in suc- 
cessful operations upon the uncured patients of 
rival surgeons. 

When none of the accidents to be hereafter 
mentioned, have followed a first operation, it is 
probable that no ill effect will result from its repeti- 
tion ; and it is better worth trying, when there is a 
chance that a previous operation was incomplete. 

BAD RESULTS OF THE OPERATION. 

Among the bad effects of a large division of the 
tissues, are the following : 

Strabismus in a direction opposite to that of the 
original deformity. It demands the reverse of the 
treatment before indicated for a partial correc- 
tion of the deviation. A compensating operation 
upon the contracting muscle has also been resorted 
to ; which, while it may relieve the deformity, tends 
to abridge the lateral motions of the eye. 

Exophthalmy. The ocular globe, deprived of a 
considerable portion of its muscular and tendinous 
ties, advances in the socket, either upon its antero- 
posterior axis, or with a lateral inclination. An 
unsightly deformity is thus produced, which is be- 
yond the aid of art. In certain cases, when slight, 
and when it occurs immediately after the operation, 
it subsequently disappears. 

Depression of the Caruncula often accompanies 
the last deformity, and more frequently exists alone. 
It is less liable to occur when the incision is made 



40 STRABISMUS. 

near the cornea, than when at the angle. It is 
irremediable. 

Gaping of the Lids sometimes occurs when the 
dissection is extensive. Phillips pretends to avoid 
this accident in many cases, by prolonging the 
conjunctival incision downwards, no farther than 
the centre of the muscle. 

If the falling of the lower lid be considerable, the 
deformity can only be remedied by a corresponding 
modification of the other eye. For this purpose the 
mucous coat is seized by two hooks, near the inser- 
tions of the inferior straight muscle, and incised. 
The unsupported lid then falls, and the similarity 
of the eyes renders the deformity less obvious. 

Immobility of the Globe. When a single muscle 
has been divided, the movements of the eye, im- 
peded at first, tend to reestablish themselves at a 
subsequent period. If two muscles are divided, it 
is probable that the movements will be less com- 
pletely restored ; and when the denudation is con- 
siderable, the eye inclines to contract firm adhesions 
to the surrounding tissues, which terminate in an 
incapability of motion, more or less complete, with 
or without strabismus. It is analogous to that pro- 
duced by deep-seated inflammation, which has been 
before described. 

Diplopy. Double vision not unfrequently fol- 
lows the operation, and disappears in most cases, 
in three weeks or a month, provided the pupils 
assume a normal position. 



CICATRIZATION. 41 



CICATRIZATION OF PARTS AFTER THE OPERATION. 

Until recently, little has been established upon 
this point. From the comparatively few authentic 
recorded observations, the following principles are 
drawn : — 

1. If any undivided fibres retain the muscle in 
place, the severed ends are apt to reunite. 

2. If completely divided, the posterior portion 
retracts, and in rare cases is inserted, fleshy, into 
the sclerotic, at a point remote from its original in- 
sertion. 

3. It more commonly contracts tendinous adhe- 
sions with the sclerotic, near the extremity of its 
transverse diameter, and becomes united to the 
anterior divided portion, by fibrous prolongations, 
which are firmly attached to the globe. 

DIMNESS OF VISION. 

Dimness of Vision is a frequent companion of 
strabismus, and has been considered its effect. 

It is certain, that in the common form of strabis- 
mus, when the disabled eye is brought into use, it 
acquires, in a large majority of cases, a new and 
often complete power of vision. This improve- 
ment is sometimes immediate, and sometimes 
gradual. 

The enfeebled sensibility of the retina, is occa- 
sionally so considerable, as to have been mistaken 
for amaurosis. It is not, however, a contra-indica- 



42 STRABISMUS. 

tion of the operation, as it results in a great number 
of cases from the deformity. 

MYOPY. 

Internal Movements of the Eye. It is evident 
that the internal relations of the different parts 
of the eye must be changed, in order to obtain 
successively, a correct image of a near, and of 
a distant object. This alteration is difficult to ap- 
preciate, and theories upon the subject have not 
been wanting. The convexity of the cornea 
has been supposed to vary ; the humors to change 
their form ; the crystalline, its figure, and more 
recently, its position ; and perilenticular canals 
have been demonstrated, * which, with that of 
Petit, serve as safety valves for the temporary 
escape of the fluids compressed by the movements 
of the lens. If this action is obscure, its imme- 
diate cause is much more so, and is not clearly 
shown to exist either in the oblique or the recti 
muscles exclusively, as different writers have sug- 
gested. 

In the experiments of M. Bonnet, 2 upon the eye 
of an albino rabbit, a distinct image of a distant 
window was obtained upon the retina. The eye 
was then laterally compressed, and while the 
first image was obscured, that of a neighbor- 

1 By Jacobson of Copenhagen. 

2 A. Bonnet. Traite des Sect. Tendin. et Muse. p. 207. Paris. 
1843. 



INTERNAL MOVEMENTS OF THE EYE. 43 

ing lamp became distinct. The experiment being 
repeated, it was inferred that lateral compression 
of the eye, placed it in conditions favorable to 
the perception of near objects ; and it seemed 
probable that the position of the oblique mus- 
cles in the human eje, best adapted them thus to 
modify the organ. 

Myopy with Strabismus, If this be true, it will 
be readily conceived that an exaggerated contrac- 
tion of the straight muscles, also compressing the 
ocular globe in their position as tangents to its cir- 
cumference, would diminish its capacity for viewing 
distant objects, and induce a state of myopy, or 
near-sightedness. This theory is confirmed by the 
fact, which is I believe established, that the form of 
the lesion which accompanies strabismus, disappears 
in a majority of cases after the operation. 

Myopy without Strabismus. Attention has been 
of late directed to the section of different muscles, 
in the common form of myopy, without strabismus ; 
but the results of these experiments are wholly un- 
satisfactory. MM. Guerin and Cunier have report- 
ed cases of relief, after section of the external and 
internal rectus. M. Bonnet claims similar results 
from the section of the inferior oblique ; 1 and hence 
infers, that a section of either of these three mus- 
cles exercises a certain influence upon the vision. 
He prefers the inferior oblique, as being easiest of 
access. In his method, it is reached by plunging 

i Op. cit. p. 231. 



44 STRABISMUS. 

a short, pointed tenotome through the lower lid, at a 
point just above the centre of the edge of the bony 
orbit. The knife is carried backwards and in- 
wards, nearly to the ethmoid, the edge being di- 
rected towards the nose. The handle is then de- 
pressed toward the outer angle of the eye ; and 
the blade thus brought forward, is found to have 
hooked up the muscle, which it subsequently di- 
vides. 

DIPLOPY. 

It was before remarked, that the variety of double 
vision which follows the operation, requires only 
time to disappear. 

When it exists before the operation, it is gene- 
rally relieved by it. A dilated state of the pupil 
in the affected eye, seems to contribute to it ; and 
in rare cases it has been observed to accompany 
vision in a single eye. 

KOPIOPY. 

Is a name given by M. Petrequin, 1 to the sensa- 
tion of fatigue experienced in the use of the affect- 
ed organ, either before or after operation. It seems 
to result from the want of power in a part rarely 
exercised, and subsides as the eye becomes habit- 
uated to its restored functions. 

1 Annales d'Oculistique, 1841. 



NYSTAGMUS. 45 



NYSTAGMUS. 

Or convulsive trembling of the eye, is observed 
with or without strabismus. The ocular globe 
oscillates in different directions, varying with the 
muscles in fault. It turns in certain cases upon 
its antero-posterior axis, as if moved by the main- 
spring of a watch attached to this axis. This mo- 
tion corresponds with that before referred to the 
oblique muscles. 

When the affected muscles are divided, the con- 
vulsive action ceases, but generally returns with 
the reunion of the parts. If we believe M. Phil- 
lips, it is then much less marked, and diminishes 
until it disappears. Of four or five patients operat- 
ed upon by M. Velpeau, none were radically cured. 

STATISTICS. 

Subjoined are the results of Velpeau and Phil- 
lips, as they have reported them. 

Velpeau. — Three hundred cases. — One half 
completely successful. Of the other half, one-third 
presented a very slight deviation, exophthalmy, 
depression of the caruncula, fixedness of the ball, 
or enlargement of the lids. In the two other 
thirds, these accidents were very manifest, and the 
patients retained a deformity as striking as that 
which existed before the operation. 

Phillips. — One hundred cases. — Seventy-five 



46 STRABISMUS. 

satisfactory results ; sixteen incomplete ; five not 
improved ; in five the eye directed outwards. Of 
divergent Strabismus, ten satisfactory, five incom- 
plete, one not improved. 

The constant success reported by DiefTenbach, 
induced a M. Melchior to examine a number of his 
patients. In a Latin essay upon the subject, pub- 
lished at Copenhagen, he states that of forty-four 
patients, but ten were found to be entirely relieved, 
and fifteen partially so/ 

The results of Bonnet, Chassaigne, and Baudens, 
are before me ; but the bearing of their statistics is 
less obvious, as they interpret differently the term 
success. 



STAMMERING. 



The operation for strabismus suggested that for 
stammering. When it was ascertained that spas- 
modic contraction of the muscles of the eye, was 
relieved by their division, it was inferred that the 
proposition was general, and a new field was sought 
for its application. The characteristics of stam- 
mering were too obvious to escape notice, and 
hence the operations for its cure. 

DierTenbach in Germany, and soon after Vel- 
peau and Amussat in France, announced their 
methods. 

The results have not answered expectation, as 
might have been inferred from the complicated na- 
ture of the mechanism of the vocal organs. But 
such was not the belief of surgeons, and the 
tongue was carved and tied, above and below, in 
any way which seemed to offer a possibility of 



48 STAMMERING. 

modifying its previous physiological conditions. 
The different operations were indiscriminately ap- 
plied. It sufficed that a man stammered, and the 
genio-glossi muscles, or the entire thickness of the 
tongue, were condemned to the knife. 

As was natural, a few patients improved, after so 
severe a lesion of the parts more or less concerned 
in the affection. Phillips states the proportion at on- 
ly five per cent. ; an estimate which has called forth 
the remonstrances of more ardent advocates of the 
operation. Allowing for exaggeration, the method 
of Dieffenbach, the bisection of the root of the 
tongue, seems to have been followed by greater 
success, but is by far the severest operation. 

It is evident that the machinery of articulation 
has not been adequately analysed, with reference to 
the operation, and that the indications of derange- 
ment of its various parts have been too little con- 
sidered. A first step then, towards the study of 
this affection, is an analysis of the articulate sounds, 
and of the manner of their production, of which, 
a sketch proportioned to the limits of this paper is 
here offered. 

The mouth, including the trachea and the lips, 
may be considered as divided at will by four dia- 
phragms, necessary to articulation, and capable of 
intercepting, both wholly or in part, the air expel- 
led by the lungs. The first of these is the vocal 
chords ; the second, the root of the tongue ; the 
third, the tip of the tongue ; and the fourth, the 
lips. To these four, each by itself, or aided by the 



STAMMERING. 49 

nasal cavity, may be referred most, if not all, 
articulate sounds. 

1. The vocal chords, by their vibration, produce 
the voice. To them is due only such articulation, if 
we may so call it, as is produced by their sudden re- 
laxation, when it coincides with an expulsive effort 
of the lungs ; an effort termed by elocutionists, ex- 
ploding. They antagonize each other. 

2. The root of the tongue, is opposed by the 
soft, and the posterior extremity of the hard 
palate, as in k. 

3. The tip of the tongue is antagonized by 
the front upper teeth, and by the bony palate, 
as in the, t. 

4. The lips are opposed, either one to the 
other, or the lower one to the upper front teeth, as 
in p, ph. 

Sounds are modified by two conditions of each 
articulating isthmus. 1 ; when shut ; 2 ; when par- 
tially opened. Thus with the lips, p, f; with the 
tip, t, th ; with the root, k and ch in the German 
nicht. The same sounds are modified by the ad- 
dition of the voice, thus, without the voice p ; with 
the voice b ; so t, d, k and g hard. 

A third and last alteration of the same sounds, 
is effected by the opening of the nasal cavities, by 
which b becomes m, d, n, and g hard, ng. 

Such are the regular principles of articulation. 
To these may be added three exceptional and 
irregular sounds, produced by the tip of the tongue 
against the hard palate. 



50 



STAMMERING. 



1. A whistle analogous to the whistle of the 
lips, as in s, and a little farther back, sh. 

2. The sound of /, produced by the lateral ap- 
plication of the tip and edge of the tongue to one 
side of the hard palate, while the air passes by the 
other side. 

3. The vibration of the flexible extremity in the 
letter r. 

This sketch may be condensed, as in the follow- 
ing table. 



6 
%-. 

°^ 
o 
o 
P5 


partly- 
open 






M 


p 
L jt 

m 




P 


6< 


fH 


r I' 6 - 1 




| £ " 




© 
p 
£P 
o 
E-i 

^< 

o 

Pn 

H 


S-l 

P. 


2 ^ 


fcJD 

.3 

"S3 

_,P 


•> — 9 

N 




rP 

CO 


5 

bo 

L © 

H 


"5c 

p 

O 




fee 


2 
as 


h3 


P 


- 


Pa< 

3 


partly 
open 


~f> 




p* 


p 
,p 

02 


rQ 


s 


P* 






"c3 

p 


1-1 
■1* 



STAMMERING. 51 

(1.) The letter v though formed between the front 
upper teeth and the under lip, is identical with the 
sound produced by a slight separation of the lips ; 
as in the Spanish Habana, pronounced like the 
English Havana, though formed by the lips. In 
the latter case, it is somewhat exaggerated. 

(2.) Were the palate flat, it is probable the sound 
th would be produced by the position of the tongue 
which now forms 5 ; to avoid which, its extremity 
is advanced to the teeth. 

(3.) The concavity of the palate, with the similar 
opposing one of the tongue, produces the whistling 
s and z, A short distance farther back it is more 
diffused, and becomes the hissing sh, and French j, 
as mj arret. 

(4.) That r is a vibration, is shown in its exag- 
geration in the Italian language ; thus giorno ; aver 
for avere. 

(5.) L is an irregular sound, produced by a partial 
but firm interception of the current of sound, by 
the tip and edge of the tongue applied to the palate. 

(6.) Ch in the German nacht, is perfectly analo- 
gous to ph and th in English. 

It will be seen that this table refers only to the 
enunciation of the consonants, which may be con- 
sidered as the interruptions and interceptions of the 
vowels, and therefore more immediately concerned 
in the defect of stammering. The original sound 
produced by the vocal chords, is modified, but not 
intercepted, during the production of a vowel. A 



52 STAMMERING. 

complete interruption occurring after the sound has 
left the larynx, forms a consonant. 

If stammering, in its common forms, be a spas- 
modic contraction of the muscles concerned in the 
mechanism of articulation, it is probable, although 
direct proof is wanting, that it may exist at either 
of these four points, and that each may be the seat 
of a variety of the affection, which it becomes im- 
portant to distinguish from the rest. Some indica- 
tion of the character of the affection, may be drawn 
from that of the sounds emitted. But this is an 
uncertain test. An anterior portion of the mechan- 
ism, if deranged, will be liable to interfere with 
that behind, and vice versa. Thus p masks t, and 
t interferes with the articulation of p. When in 
confirmation of these views, w T e consider the dif- 
ferent degrees of this affection, from the simple lisp, 
to the confirmed stammer accompanied with dis- 
tressing convulsions of the whole countenance, it 
is evident that the lesion is a complicated one, 
and that in its different forms, it demands a different 
treatment. We cannot but wonder at the temerity 
of surgeons, who when the patient stammered, at 
once condemned him to the knife, and indifferently 
divided the genio-glossi muscles, or subjected the 
entire tongue to a bloody bisection, with a vague 
intention of modifying its nervous condition. 

An adjustment of the machinery of articulation, 
can be based only upon a thorough analysis of its 
complicated action. An outline of this analysis may 
be found in the foregoing table, and such must be the 



HISTORY. 53 

groundwork of any future efforts to identify the dif- 
ferent forms of this affection. 

The remainder of this article, will be devoted to 
an account of the different operations, which have 
been of late years practised in this affection. 

HISTORY. 

• The French Journal des Debats of January 2d, 
1841, contained the following original announce- 
ment at Paris, of the operation of Dieffenbach. 

" We read in a German paper, that a discovery 
of Professor Dieffenbach, excites at Berlin, general 
attention. This surgeon has found the means of 
curing stammering by an incision of the tongue. 
The operation he has performed, has completely 
succeeded. According to Dieffenbach, stammering 
arises from an impossibility of applying the tongue 
to the palate. His method consists in putting an 
end to this inconvenience." 

These indications were not lost upon the French 
surgeons. Some of them laid claim to previous ver- 
bal suggestions of an operation. Others, adopting 
the principles hinted at by Dieffenbach, sought to 
discover his method ; and hence resulted what is 
known as the French operation. It was announced 
nearly simultaneously by Amussat, Phillips, Baudens 
and Velpeau. It subsequently appeared, however, 
that the surgeon of Berlin employed a different me- 
thod. With the intention at once, of enabling the 
patient to antagonize the tongue with the roof of the 



54 STAMMERING. 

mouth, and of " changing the innervation," he prac- 
tised a deep transverse section, sometimes with loss 
of substance, at the root of this organ. 

The French method had reference only to the 
liberty of the tip of the tongue, and consisted in 
the division of the genio-glossal muscles and other 
parts beneath. 

The different French operations are essentially 
the same, and the literature upon this subject re- 
lates chiefly to the operation, and is, for the most 
part, polemic in its character. 

METHODS OF DTEFFENBACH. 

The theories upon which DiefTenbach founded 
his operation, are explained in the following quota- 
tions. 

1. " Shortening of the muscular substance" 1 It 
is especially upon this last method, (excision of a 
piece of the tongue,) " that I have founded the great- 
est hope ; because it had for its result, the shorten- 
ing of the tongue, and enabled it to touch the su- 
perior wall of the buccal cavity ; a movement, the 
developement of which is especially sought." * * * 
(P. 436) " The patient, after operation, has a sen- 
sation of a shortening of the tongue, and of an 
elevation of the point against the palate." 

2. Change of Innervation. " As I thought that 
the derangement in the mechanism of language 

i Dieff. in the Annales de la Chirurgie Fran^aise et Etrangere. 
Paris, 1841. t. i. p. 422. 



METHODS OF D1EFFENBACH. 55 

which produces stammering, had a dynamic cause, 
which I regarded as a spasmodic state ^of the air 
tubes, which resided especially in the glottis, and 
which was communicated to the tongue, to the 
muscles of the face, and even to the neck, I ought 
to conclude that, by interrupting the innervation in 
the muscular organs, which participate in this 
anormal state, 1 should succeed in modifying it, or 
in causing its complete cessation. 

" It is for this reason that the transverse section 
of the muscular substance of the tongue, seemed 
to be an enterprise worthy of being attempted, and 
of which the success seemed to be infallible ; like 
the efficacy of the transverse section of muscles, in 
a great number of spasmodic affections." 

To accomplish these ends, Dieffenbach employed 
successively, three different methods. 

1 . A horizontal transverse section of the root of 
the tongue. 

2. A subcutaneous transverse section of the root 
of the tongue, preserving the mucous coat. 

1 3. A horizontal section of the root of the tongue, 
with excision of a triangular piece, in its entire 
breadth and thickness. 

A. Method of Excision. The patient is seated, 
his head supported against the chest of an assistant. 
The tongue is protruded and seized upon its edge, 
by the teeth of a " pince de Museux." Thus 
laterally compressed, it gains in thickness, a con- 

1 Lettre a l'Acad. Roy. des Sciences ; printed at Berlin. 



56 STAMMERING. 

dition favorable to the operation. Being then car- 
ried forward and a little to the right, by one aid, 
while another draws apart the angles of the mouth 
with blunt hooks, the root is seized by the thumb 
and fore-finger of the operator's left hand, laterally 
compressed, and raised. The blade of a bistoury, 
edge upward, is entered at the left side of the root, 
penetrates to the opposite surface, and cuts its way 
out from below upwards. The posterior edge of 
the wound being fixed by a strong suture, the ante- 
rior border is seized with toothed forceps, laterally 
compressed, and cut off with a narrow bistoury. 
The piece thus removed is wedge shaped, the base 
about three-fourths of an inch in breadth, correspond- 
ing to the mucous surface, and has been compared 
to a slice of melon. The posterior edge is then 
brought forward by means of the suture and a small 
hook, and united to the anterior edge by six strong 
points of suture, which, traversing the bottom of the 
wound, impede hemorrhage. 

In subsequently removing the first ligature, if it 
be followed by an oozing of blood, it is an announce- 
ment that the cicatrization is not yet solid, and the 
surgeon should desist. This fact, and the manner 
of arresting the hemorrhage by deep sutures em- 
bracing the mass of the tongue, may serve as 
hints for other operations upon these parts. 

B. The Simple Section of the root of the Tongue 
resembles the preceding method, without the re- 
moval of the wedge shaped mass. 

C. Subcutaneous Section of the root of the 



FRENCH OPERATION. 57 



Tongue. In this operation, the upward section 
terminates, before dividing the mucous coat upon 
the superior surface of the tongue. 

DiefFenbach thus speaks of the dangers of the 
operation : 

" The loss of the tongue by gangrene or by ex- 
tensive suppuration, or even by the want of dex- 
terity of the assistant who may easily tear it, are 
considerations which require to be maturely weighed, 
and which, joined to the difficulties which it pre- 
sents, will hinder operators of little experience from 
wishing to attempt it." 

FRENCH OPERATION. 

The propositions of the French surgeons em- 
braced the principal points presented by DiefFen- 
bach. The conditions supposed to accompany 
stammering, indiscriminately in all its varieties, are 
thus enumerated. 

1. Slight deviation of the tongue to the right or 
left. 

2. Impossibility of pressing the tip of the tongue 
against the upper lip, without the aid of the lower 
jaw, which advances to support it. 

3. Spasmodic agitation of the tongue during the 
act of phonation. 

To these Velpeau, Amussat, and others, added a 
fourth proposition. 

4. A remarkable developement of the genio-glos- 
sal muscles, the frenum being strong and hard. 

8 



58 STAMMERING. 

The division of these muscles is the aim of the 
French operation. The different methods are sub- 
joined. 

Method of Phillips. The patient is seated, as in 
the operation of Dieffenbach. The surgeon seizes 
the frenum at its angle of reflection upon the 
tongue, with a hook, bent at right angles, that it 
may not impede his subsequent manipulations, and 
confides it to an aid. He then implants a second 
small hook in the frenum, at a half line distance 
from the ducts of Wharton, and between the two 
hooks, divides largely the mucous coat, with scis- 
sors. Laying aside the scissors, he introduces by 
the wound, a blunt hook edged upon its concavity, 
and collecting upon it " all the muscular mass of 
the tongue," divides it with a sweep of the instru- 
ment. 

Phillips, it is seen, severs the muscle near its 
fanlike expansion in the tongue. The other 
methods deal with a point nearer the jaw, where 
the muscle is less voluminous and less vascular. 

Methods of Velpean. 1. The tongue is held by 
the left hand, armed with a linen, and drawn aside. 
A puncture is made with a lancet, at the right of 
the frenum near the under jaw. A tenotome is 
plunged in the aperture, to the depth of three-fourths 
of an inch, and the genio-glossal muscles are divided, 
without enlarging the incision of the mucous mem- 
brane. 

2. In another case the section was made with 
scissors. 



FRENCH OPERATION, 59 

3. In a third patient, M. Velpeau removed a tri- 
angular mass from the point of the tongue, and the 
wound was brought together by sutures. 

4. In a fourth, the anterior pillar of the velum 
palati, which contains the palato-glossus muscle, 
was divided, but without success. 

5. At a subsequent operation, this surgeon stran- 
gulated by ligature a mass, resembling in size and 
position, the wedge removed in the operation of 
Dieffenbach. The tongue being drawn forward, 
was traversed at its root by a needle, armed for 
strength with four threads. Two were tied over 
the back of the tongue. The two others were tied 
in the same way, a little in advance of the first, 
thus insulating a portion of the tissues, which sub- 
sequently sloughed away. 

Method of Amussat. The surgeon first divides 
the frenum, with the mucous membrane on each 
side, and the salivary glands, avoiding the ducts of 
Wharton. If no advantage is gained, the genio- 
glossal muscles are divided near the apophyses. 
If, during this process, the tongue be thrust for- 
ward and upward, the muscles spontaneously offer 
themselves for section, and are easily divided with 
knife or scissors. 

Of Baudens. This surgeon employs pointed 
scissors bent at an elbow near the pivot, like Roux's 
scissors for the operation of staphyloraphy. Slightly 
opened, they are thrust to some depth astride the 
genio-glossal muscles, which are then divided at a 



60 STAMMERING. 

single stroke. The genio-hyoid muscles are some- 
times included in the section. 

Of Lucas of London. The mucous membrane 
and cellular tissue, are dissected to the extent of an 
inch, in the method of this surgeon, for the purpose 
of exposing and avoiding the ranine arteries, the 
large veins, and a branch of the lingual nerve, which 
borders the outside of each muscle. The muscles 
are divided, and a triangular fragment whose base 
corresponds to the surface, is detached. 

Subcutaneous Operation. M. Bonnet has pro- 
posed a puncture beneath the chin, at the distance 
of an inch behind it. A tenotome is introduced, 
and thrust upward, its edge toward the bone. 
When it is perceived beneath the mucous mem- 
brane, the surgeon feels for the insertion of the 
genio-glossal muscles, and cuts to the right and left. 
By keeping the edge of the tenotome against the 
jaw, and acting only upon the superior part of 
the convexity of the bone, upon a median line, the 
insertions of the genio-hyoid muscles are avoided. 

ACCIDENTS AFTER THE OPERATION. 

Hemorrhage. The vascularity of the parts, the 
size of the incision, and the difficulty of command- 
ing the bleeding vessels, are conditions which give 
rise to formidable hemorrhage, with difficulty arrest- 
ed by means more painful than those employed to 
remedy the stammering. It is obviously difficult to 
amass evidence upon this point. At a time when 



ACCIDENTS AFTER THE OPERATION. 61 

surgeons emulated each other in reporting success- 
ful results from the operation, various motives in- 
duced misrepresentation. But the danger of hem- 
orrhage is not altogether concealed. DiefTenbach 
says of his own subcutaneous method, " The blood 
gushed with abundance from the two lateral wounds, 
as if it escaped from a large arterial trunk ; and 
the tongue soon became tumefied, by the mass of 
blood which accumulated in the interval of the sub- 
cutaneous section." The books allude to a student 
at Berlin operated upon by this surgeon, who died 
from the profuse bleeding attendant upon the opera- 
tion. 

Phillips says of this method, "It is surrounded 
with too many dangers to be retained in practice. 
The hemorrhage is always very abundant, and we 
possess no means to arrest it, unless by a second 
operation, more painful and more cruel than the 
first." And in another place, " The hemorrhage 
which follows this operation is of long duration ; 
and I felt the greatest anxiety, after having operated 
upon a young man of Liege. The section of the 
muscles was made at eleven o'clock in the morning. 
At eight o'clock in the evening, the blood still gush- 
ed, as from the mouth of an open artery." Again, 
" I have seen patients, in my practice, lose blood 
seven or eight hours after the operation, without the 
possibility of arresting it." 

M. Guersent, surgeon of the Hopital des Enfants, 
has published a remarkable case of this kind, in 
which the patient, a child of twelve years, was pre- 



62 STAMMERING. 

disposed to hemorrhage. After the operation, by 
Amussat's method, the hemorrhage commenced, 
and was renewed at intervals for ten days. During 
this time every means were employed to arrest the 
bleeding ; styptics, balls of charpie, cold lotions, 
and finally the actual cautery, which was renewed 
seven times. At the end of ten days the patient 
presented a state of almost complete anemia, from 
which it slowly recovered. At the end of three 
weeks, the child stammered as before, the tongue 
being much shorter after the operation. 

The bleeding is promoted by the inclination 
which patients have, to suck blood from the wound. 

The hemorrhage should, in common cases, be 
treated by the injection of iced water; tamponne- 
ment ; plugging with balls of lint, wet with alum or 
some other styptic solution. In the operation of 
DierTenbach, the bleeding is impeded by deep 
sutures, which are drawn tight, thus compressing 
the mass of the tongue. The hemorrhage is usu- 
ally arrested, by the formation of a more or less 
voluminous clot, w T hich should not be disturbed. 
Phillips alludes to two cases of obstinate hem- 
orrhage, following the removal of the coagulum. 

Tumefaction of the Tongue. The enlargement 
of the tissues, often considerable during the in- 
flammatory action, is sometimes such as to hazard 
the life of the patient. 

1 " Everybody knows the deplorable story of 

1 Phillips, Tenot. sonscut, p. 392. 



ACCIDENTS AFTER THE OPERATION. QS 

a young man operated upon, whose tongue ac- 
quired a considerable volume. It formed upon the 
lower wall of the mouth a vast valve. During the 
night, the symptoms became more and more alarm- 
ing, and the result was finally enveloped in a pro- 
found mystery. How many other examples have 
had the same fate ! " 

In the Gazette des Hopitaux, (Juin 1, 1841,) 
M. Amussat has avowed one case of death. The 
subject had been operated upon, in presence of 
a commission named by the Academy. The same 
journal contains also the history of a man who came 
near dying of asphyxia, by the enlargement of the 
tongue. 

The tongue, left to itself after the section of the 
genio-glossal muscles, exercises a great force of re- 
traction, and has a tendency to turn back upon the 
glottis, an accident which it has been shown may 
be fatal. A similar accident is to be apprehended 
from the posterior portion of the tongue, in the 
transverse dorsal incision of Dieffenbach, and hence 
the care requisite to secure it during the operation, 
by means of a suture or a hook passed through its 
substance. 

APPRECIATION OF THE DIFFERENT METHODS. 

In estimating the comparative value of the differ- 
ent methods, a first ground of comparison, unques- 
tionably the most important, is their efficiency in 
relieving the imperfection of articulation. The 



64 STAMMERING. 

inadequacy of the operation in a majority of cases 
seems generally to be conceded. It has been shown 
theoretically, that in its application to a part only of 
the articulating machinery, it is incomplete. But 
such an avowal is not to be looked for in papers upon 
this subject ; the aim of most of which is to herald 
the success of a new operation, and to give noto- 
riety to its advocates. 

To this remark there are exceptions. DiefFen- 
bach considers the operation inapplicable in certain 
cases, and allow r s that in what concerns the indica- 
tions of the operation, they are much more difficult 
to determine than in the operation for strabismus. 

Of the French operation, Phillips thus speaks. 
" Among true stammerers, there are some who re- 
double the 6, p, d, t, and who pronounce for ex- 
ample b, 6, b, 6, a, &c. These may be improved 
by the section of the genio-glossi, but not radically 
cured ; the lips play a too considerable role in the 
articulation of this letter. Those who redouble the 
t, and the a, may be radically cured by the sec- 
tion of the genio-glossi, if there is not at the same 
time some defect in the respiration. Stammering 
upon s and z may be also diminished by the opera- 
tion ; but if it bears upon the h, k, and m, the opera- 
tion is without effect. I have never, up to the 
present day, been able to appreciate the least change 
upon these letters after the operation." 

These observations are cited, as confirming the 
analysis of sounds laid down by the writer in the 
beginning of this article. 



APPRECIATION OF THE DIFFERENT METHODS. 65 

The articulation of the consonants mentioned by 
Phillips, as affected by the section of the genio- 
glossi, will be found referred in that table to the 
tip of the tongue, and consequently directly influ- 
enced by the liberty of that part of the organ. 

M. Chassaigne, 1 another writer upon this sub- 
ject, in opposing this theory of Phillips, cites a 
case in which the pronunciation of the sentence 
" Maman m?a mande" was facilitated by the sec- 
tion of the genio-glossi. It is probable that in this 
case the affection existed, not in the labial muscles, 
but in those of the tip of the tongue, the spasmodic 
action of which, masked or impeded the labial ar- 
ticulation. Such mistakes have arisen from an 
insufficient study of the varieties of the affection. 
In most reported cases, it sufficed that the patient 
was unable to articulate certain test words, like 
those alluded to, or " Kakoski, Colonel des Cos- 
saques" "hippopotamus ," " concupiscence ," and he 
became a subject for the operation, according to 
the method then in vogue. If after this lesion of 
the buccal cavity, the spasmodic action of the mus- 
cles ceased for a time, the operation was proclaimed 
satisfactory in its result. Such has been the opera- 
tion I have often witnessed in the Paris hospitals, 
and such are the majority of printed observations. 

Authors seem to allow to Dieffenbach, a greater 
share of success than to other surgeons. No means 
of estimating the value of his assertions upon this 

1 Trait6 du Strabisme et du Begaiement. Paris, 1841, p. 140, 
9 



i3 STAMMERING. 



point are at hand. It is however difficult to give 
full credit to statements like the following. 1 " I 
have within a short time operated upon fourteen 
stammerers, in removing a triangular piece of the 
tongue, and in all, the stammering has entirely 
ceased." It may be suspected that at the end of a 
longer period it returned, at least in some of the cases. 

It is easy to imagine that in promiscuous opera- 
tions upon the different varieties of the affection, 
the section of DiefFenbach, which involves all the 
lingual muscles, should more readily alter the func- 
tional conditions of the tongue, than the division of 
the genio-glossi alone. But if the division of 
muscles be its object, this method attacks indiscrim- 
inately the interweaving fibres of all the fasciculi, 
without bearing directly upon the body of either of 
them. On the other hand it is difficult to establish 
how far it may alter the innervation of the part ; 
neither is this proved to be the essential end of the 
operation. If the previous length of the lingual 
surface interfered with the power of opposing the 
tip to the palate, the removal of a portion of the 
dorsum might tend to obviate this difficulty ; but 
much less directly than the division of the genio- 
glossal muscles. 

Until the applicability of the German operation 
be clearly indicated, and its efficacy shown, the 
profuse and dangerous hemorrhage, the tumefac- 
tion, and other inflammatory accidents to which 
it is liable, are insurmountable objections to it. 

1 Dieff. Gazette des Hopitaux. Mars. 18, 1841. 



STATISTICS. 67 

The same is true in a less degree of the French 
method, which however probably applies to a 
greater number of cases, and is less objectionable, 
when the point of section approaches the jaw-bone, 
as in the subcutaneous section of Bonnet, which is 
confined to the tendinous insertions of the muscles. 
The analogy of this method to the simple section 
of the frenum in tongue-tied children is obvious'. 
It is sometimes employed with advantage where 
the tongue is not confined, where the spasmodic 
condition of the genio-glossi muscles can be clearly 
demonstrated. 

The method of Velpeau, by ligature, offers a 
smaller chance of hemorrhage, but is even more sub- 
ject to violent inflammatory accidents. The removal 
of a triangular mass from the anterior part of the 
tongue and from the genio-glossal muscle, the divis- 
ion of the genio-hyoid and other equally fanciful 
sections, are evidently experimental. 

Authentic statistics of the results of these differ- 
ent operations will not be expected, when the 
unscientific character of most of the papers upon 
this subject is considered. 

The following results, those of Dieffenbach ex- 
cepted, refer to the French method. M. Baudens 
says, " we count at this time twenty-one persons 
operated upon by our method. All have obtained, 
if not an absolute cure, a notable amelioration." It 
is sufficient to add, that of strabismus, the same 
author remarks, " of eight hundred squints that we 
have operated upon, * * * in every case we have 



68 STAMMERING. 

succeeded ; let skeptics put us to the test ; let them 
give us the most desperate cases, and when we 
have failed once, we will yield to the evidence." 
Such assertions need no comment. 

Dieffenhach has been elsewhere quoted, " four- 
teen cases operated upon, among all of whom the 
stammering has entirely ceased." 

Chassaigne, among seventeen cases, gives seven 
cured, five ameliorated, and five without beneficial 
result. 

Finally, Phillips concludes his essay as follows : 
" of one hundred individuals speaking badly, called 
improperly stammerers, we find only five subjects 
really stammering ; and these alone are fit to be 
operated upon with success. Of these five individ- 
uals, we count two or three who stammer only 
upon the lingual letters. In these cases the opera- 
tion is brilliant in its results ; the stammering 
ceases entirely. The two others stammer upon 
linguals and labials, and then the operation affects 
the stammering of the linguals alone, and hardly 
modifies the stammering of the labials. 

" I have seen in the service of M. Velpeau a case 
of brilliant success, after an operation upon a sub- 
ject who stammered, i. e. redoubled the linguals. 

" The ninety-five other individuals do not stam- 
mer, but speak badly ; either because they shut the 
mouth in trying to talk, or because they do not 
breathe, or because they cannot or do not know 
how to make use of the tongue to aid articulation, 
or finally because they have nothing to say." 



TENOTOMY. 



The division of tendons is an operation of ancient 
date. Tulpius, in 1685, refers to Isacius Minim, 
as having practised it. It was at that time consid- 
ered a grave and dangerous operation, and de la 
Sourdiere in 1742, terminates a memoir in the fol- 
lowing words. " The section of tendons ought then 
to be avoided." In 1782 or 1784 Lorenz divided 
the tendo-Achillis at the request of Thilenius, a 
physician of Frankfort ; and Michaelis soon after 
effected, though incompletely, the same section. 

Until recently, it was the custom of surgeons to 
incise the integuments with the tendon, the severed 
extremities of which were freely exposed to the air. 
In these conditions, the divided tendinous surfaces 
remain for a length of time pale. Slowly they be- 
come vascular, granulate, until the vegetations fill 
the surrounding void, and finally heal, with a dense 



70 TENOTOMY. 

firm cicatrix, which involves cellular tissue, apon- 
euroses and integuments. The sliding of the ten- 
don is thus impeded, and in its restricted move- 
ments, it bears with it the surrounding and adher- 
ing tissues. The restorative process is in such cir- 
cumstances tedious ; and the constitutional reaction, 
and consequent hazard to the patient considerable. 

At the present day, the division of tendons is a 
trifling operation, and almost divested of danger. 

Delpech first proposed a section which should 
not denude the tendon. A bistoury was passed 
beneath the skin, which it traversed at two points, 
as if for the passage of a seton. The incision was 
extended to the length of about an inch, and the 
tendon was divided. 

Stromeyer and before him Dupuytren, according 
to Velpeau, indicated the method by simple punc- 
tures. The latter surgeon confined himself to a 
single orifice, which gave admission to the instru- 
ment, taking care not to wound the integuments of 
the opposite surface. This is essentially the method 
of the present time, and the most simple which sci- 
ence now possesses. It has undergone two modi- 
fications, referred respectively to Stoess and Bouvier. 

In the method of Stoess, the knife is introduced 
beneath the tendon, which is divided from within 
outwards. Bouvier enters the instrument beneath 
the skin, and divides the tendon from the surface 
towards the deep seated parts. 

The field of subcutaneous operations, effected by 
a simple puncture of the integuments, and applied 



DIVIDED TENDONS. 71 

to muscles and aponeuroses as well as tendons, has 
been widely extended by various surgeons ; among 
whom Dieffenbach and Guerin are conspicuous. 
The exclusion of air, is the aim and characteristic 
of this method. A degree of vitality is thus retain- 
ed in the injured parts, and even in the effused 
blood, which favors in a remarkable manner their 
restorative action. The functions of absorption 
and secretion are carried on with a rapidity, to 
which the presence of the atmospheric fluid seems 
fatal. 

An entirely new class of operations by this 
method, has sprung into existence, to which the 
remainder of this paper will be devoted. 

SUBCUTANEOUS CICATRIZATION OF DIVIDED TENDONS. 

It is well known that a tendon, when divided 
beneath the skin, is disposed to retract, leaving an 
interval between its extremities, at the point of sec- 
tion. In most cases the interval is obliterated, and 
the continuity of the tendon reestablished, by the 
gradual deposition of an intermediate fibrous tissue. 
Observers differ with regard to the manner in which 
this tissue is formed ; and experiments have led to 
apparently opposite results. 

Stromeyer, in attributing the deformity of certain 
club-feet to muscular contraction, asserts that the 
length of the newly formed tendon, which he com- 
pares to a thick ring, is alone insufficient to account 
for the redressment of the deformity ; and supposes 



72 TENOTOMY. 

that the muscle, once relieved from the stimulus of 
tension, elongates itself, until the divided tendinous 
surfaces are brought into contact. On the other 
hand it may be urged, that the interposed mass is 
often considerable. In one experiment of Bouvier, 
its length was nearly two inches at the end of 
twenty-four days. It is possible that the tendi- 
nous end, enlarged at its point of union with the 
newly deposited matter, may have been mistaken 
by this surgeon, for the entire substance of the 
cicatrix. 

One class of observers, among whom are Held 
and Bouvier, suppose that the tendinous sheath, 
with its surrounding cellular tissue, undergoes a 
gradual transformation into fibrous matter, with 
agglutination of its walls, and obliteration of its cav- 
ity. Others, leaning to the theory of Hunter, assert 
that the cavity of the sheath is a receptacle of blood 
and of lymph, which is afterwards organized and 
converted into tendinous fibre. Such, are Amnion, 
Guerin, Phillips, Duval. 

The result of the detailed experiments of Bou- 
vier x on one side, and Amnion 2 on the other, ren- 
der it probable that the restorative action varies in 
different circumstances, and accommodates itself to 
the pathological conditions of the parts. In the ex- 
periments of Ammon, the effusion of blood was con- 
stant ; and was probably due to a laceration more 

1 Mem. de l'Acad. Roy. de Med. t. vii. 
2Exper.,t. I., p. 155. 



DIVIDED TENDONS. 73 

or less extended, of the fibrous envelope and sur- 
rounding cellular tissue. This hemorrhage was of 
rare occurrence in the cases of Boavier ; and we 
infer that care w T as taken to divide the tendon, with- 
out injury of the neighboring parts. Whether with 
Guerin we consider the effused coagulum to be a 
condition essential to the process of restoration, or 
with Velpeau view it as an accidental complication, 
it is evident that such a body of fibrin, interposed 
between the divided tissues, must modify the pro- 
cess which nature sets up where no such foreign 
body exists. 

The experiments alluded to, seem to establish 
the following propositions. 

When the fibrous sheath is little injured, and 
when there is a free communication between the 
divided ends of the tendon, the tissue of the sheath 
becomes dense and indurated by the deposition of 
fibrous matter, and layers of cellular tissue are suc- 
cessively impacted upon its exterior. In the mean 
time, its cylindrical cavity, strangulated at the cen- 
tre, gradually contracts ; lymph is exuded in its in- 
terior ; the extremities of the tendon assume a coni- 
cal form, and uniting with the sheath, the whole 
mass finally acquires the character of a dense fibrous 
cord. 

But when the surrounding tissues are divided, 
and a coagulum is deposited in the wound ; when, 
instead of the fibrous sheath ready at hand, to be 
converted into tendon, a foreign body, as it w r ere, 
is interposed between the divided surfaces, the 
10 



74 TENOTOMY. 

process of restoration is different. While the 
wounded surfaces exude lymph, the coagulum plays 
the chief part in the formation of the new tendon. 
It becomes gradually organized. Its substance is 
penetrated with vessels, which, in their turn de- 
posite plastic matter, until the severed extremities 
are at length united by a few filaments. These 
increase in size, acquire a compact texture, and 
are fused in time into a fibrous resisting mass. 

GENERAL CHARACTERS OF DEFORMITY. 

It is probable that all congenital distortions of 
the trunk and limbs, are the result of muscular 
contraction, originally induced by an affection of 
the nervous centre or its branches. 

At the period when the surgeon is called to 
operate, it is no longer active, and he deals only 
with its results, as presented by certain modifica- 
tions of the muscles, fibrous tissues and vessels. 

The original affection, being a spasmodic action 
of the muscular fibre, has received from Guerin 
the name of contraction ; wrrle the consequent and 
permanent lesion, as exhibited in the partial or en- 
tire change of the muscular into a fibrous tissue, 
has been called by the same writer, retraction. 1 The 
duration of the state of simple contraction is in- 
definite ; and during this period, the soft parts may 

1 To this condition. Little has applied the term, " structural short- 
ening.' Lancet, Dec. 9, 1843. p. 39. 



GENERAL CHARACTERS OF DEFORMITY. 75 

be elongated by proper means. But the fibrous 
change is attended with rigidity, unyielding in pro- 
portion to the extent of the transformation. 

Most cases of club-foot present these characters, 
and date either from foetal existence, or from some 
convulsive affection of early life. Their leading 
and distinctive feature, is a tenseness of certain 
tendons, which become especially evident beneath 
the integuments, when an attempt is made to cor- 
rect the deviation. They are then rigid and salient, 
and manifestly interfere with the normal position of 
the limb. 

Retracted muscles are generally found upon dis- 
section, to be pale, atrophied, and partially con- 
verted into fibrous tissue. They are more or less 
completely paralyzed, and their developement has 
been arrested. The fatty transformation is more 
rare, and of less importance to the surgeon. It has 
been doubted whether it be possible to detect this 
lesion through the integuments. When it interferes 
with the restoration of the limb to a normal posi- 
tion, it is generally more or less combined with the 
fibrous change. 

Guerin has laid down two rules, with regard to 
the change which the muscles undergo, when thus 
permanently contracted. 

1. In all chronic deformities, the muscles, instead 
of continuing their primitive relations with the 
distorted portion of the skeleton, tend to become 
shorter, and to direct themselves in a straight line, 
between their two points of insertion. 



76 TENOTOMY. 

2. The transformation of muscles is fatty or 
fibrous ; fatty, when the muscles are compressed, 
and left to themselves ; fibrous, when they are sub- 
mitted to exaggerated traction. 1 

The tendons and ligaments seem rather arrested 
in their developement, than changed in form. In a 
state of repose, the fibrous cords become more 
compact, and are not unfrequently changed into 
bony matter. Guerin supposes that this osseous 
deposition only occurs, when the muscles become 
fatty ; but the position has been disputed by other 
surgeons. 

The arteries do not follow the muscles in their 
deviation. They are neither shortened nor tense 
and straight. " They accompany the muscular 
curves when they are attached to these muscles, 
and become tortuous when free ; the more so as 
the distance they traverse is more limited." 2 

The nerves tend to diminish in length, and to 
adapt themselves like the muscles, to the cord of 
the curve produced by the deformity. This dispo- 
sition to retract, is attributed by Guerin to the 
fibrous tissue of the neurilemma. 

The veins dilate and increase in number ; modi- 
fications, supposed by Guerin to explain the fatty 
transformations of the tissues in general. The 
tendency of the skeletons of deformed limbs to 
exude a greasy matter is well known. 

1 Vues. Gen., etc. p. 23. Paris, 1840. 

2 Op. cit. p. 25. 



INSTRUMENTS AND MANUAL. 77 



INSTRUMENTS AND MANUAL OF THE OPERATION. 

The instruments contrived for subcutaneous ope- 
rations are exceedingly numerous, and the more 
important ones will be alluded to in another place. 
Many of them offer useless complications and re- 
finements. The sections may all be effected with 
one or two tenotomes. The most useful consists of 
a blade, about an inch in length by one eighth of 
an inch wide, pointed, and slightly convex. At- 
tached to a short cylindrical shank, it serves to 
divide the larger tendons. Probe pointed, straight 
on its edge, and with a longer shank, it may be 
used for the broad or deeper-seated fibrous tissues. 
(Figs. 8, 9.) 

The tension of the tendons, is by far the most 
important of the indications for their division. 
When it is ascertained that their retraction inter- 
feres with the normal position of the part, it is 
expedient, as a general rule, to divide them ; be- 
ginning with the most rigid and salient. 

The manual of the operation is briefly as follows. 
The region being placed in a convenient position, 
the tendon to be divided is made tense, and if pos- 
sible evident, beneath the integuments. This is 
effected either by the position of the patient, by 
voluntary contraction of the muscle, or by external 
force properly directed. 

Guerin pinches up, immediately over the tendon, 
a fold of skin, one end of which is confided to an 



78 TENOTOMY. 

aid, and introduces the tenotome flatwise at its 
base. He then releases the integuments, and the 
puncture recedes to a distance from the point of 
section, while the blade retains its position near 
the tendon. The tendon is now made tense by 
active or passive flexion or extension, and divided 
by a slight sawing movement of the knife. 

It is unimportant whether the section be made 
from without, or within the tendon, if there be no 
especial indication, such as the neighborhood of 
large vessels, to guide the operation. A place of 
section should be chosen, where the tendon is sur- 
rounded by cellular membrane. It is rarely possi- 
ble to obtain union, in the cavity of a synovial 
sheath ; and permanent deformity has resulted from 
division of the tendon in this position. 

At the moment the section is completed, a noise 
is heard as the two ends suddenly recede from 
each other ; modified and exaggerated, if it be near 
the region of the thorax. The instrument is with- 
drawn as it was entered, the integuments being 
compressed as the knife recedes, to hinder the ad- 
mission of air. As the blade leaves the puncture, 
the finger arrives at and covers it, until it is effec- 
tually sealed by a bit of adhesive plaster. 

HEMORRHAGE. 

If the hemorrhage be considerable, a tumor 
occupies the seat of the effusion, and the blood is 
to be expelled by the puncture as far as practicable. 



MECHANICAL TREATMENT. 79 

It is more frequently distributed in the cellular 
membrane, and left for subsequent absorption. 
Alarming hemorrhage is rare, as the larger vessels 
are not involved in the operation. 

In some experiments of M. Amussat, which I saw 
at the Abattoir Montmartre, the open vessel, even 
when of considerable size, if completely divided, 
occupied the centre of a coagulum, the walls of 
which acquired such tenacity, as to confine the fluid 
nucleus, and arrest the effusion. 1 In deep sec- 
tions additional security is offered, by the flexibility 
of the vessels, which yield to the edge, while the 
resisting tendon is divided. Hence it is better in 
such positions, to avoid as far as possible the saw- 
ing movement of the instrument, and to divide the 
tendon by force perpendicularly applied to it. 

MECHANICAL TREATMENT. 

It is now generally allowed, that an immediate 
application of mechanical force is not indicated. 
Inflammation, re-opening of the puncture, admission 
of air and suppuration, were not unfrequently the 
sequence of the operation in past years. These 
accidents have become less common, since atten- 
tion has been directed to the cicatrization of the 
integuments, before beginning the mechanical treat- 
ment. 

i These results have been since generalized, by farther observa- 
tions upon hemorrhage in the human subject. Amussat. Common, 
a VAcad. des Sciences. Oct. 28, 1844. 



80 TENOTOMV. 

The principle of the various machines contrived 
for this purpose, is simple. Their object is to direct 
and maintain a permanent effort, against the curve 
of the deformity. A separate part of the appara- 
tus is adjusted to each detached portion of the 
skeleton, while the centres of movement of the 
machine, correspond to the articulations, and are 
fixed by ordinary mechanical expedients, such as a 
ratchet-wheel, rack and pinion, or best by a per- 
petual screw. (Figs. 16, 17, 18.) 

Of mechanical treatment without division of the 
tendon, little need be said. It is often efficient in 
infancy, and in certain cases of spasmodic and of 
slight deviation. But in a common case of chronic 
deformity, two elements oppose the return of the 
parts to a normal condition ; the distortion of the 
bone, and the tension of the unyielding fibrous tis- 
sue, which approximates its extremities. In sever- 
ing these fibres, we remove one of the chief im- 
pediments to the restoration of the part ; as is evi- 
dent from the sudden separation of the divided 
extremities. It has been abundantly proved 
that, under proper restrictions, the operation is 
safe, and that while the duration of the treat- 
ment is abridged, there is less chance of a return 
of the deformity, than when unaided mechanical 
treatment is adopted. 



CLUB-FOOT. 



Certain rare cases of this distortion result from 
idiopathic malformation, or other lesion of the bony 
tissues ; but by far the most numerous class is due 
to muscular agency. 

Club-foot has been defined to be the result, 
" of 1 inequality in the antagonizing muscular forces, 
and of the permanent retraction of certain mus- 
cles." 

CAUSES. 

Its causes may be considered in two classes, with 
reference to the period of their influence. 1 ; Con- 
genital. 2 ; Consecutive. 

1. Congenital. Among the probable influences 
supposed to act during the foetal state, are the fol- 
lowing. 

1 Traits pratique du Pied. Bot. par Vincent Duval. Paris, 1843. 
11 



82 CLUB-FOOT. 

a. An intrinsic muscular contraction, due to the 
agency of the cerebro-spinal system. As the most 
frequent cause of club-foot, it is by far the most 
important to the surgeon. It produces a large 
majority of the cases with which he is called upon 
to deal. 

b. The mechanical pressure of the uterine fibres, 
or the bad position of the child. 

The first of these causes has been investigated 
bv Guerin, who considers convulsive muscular con- 
traction as the essential cause of the congenital form 
of the distortion. His theory is founded, 1. Upon 
dissections of foetal monstrosities and deformities, 
where lesion of the nervous centre or its ramifica- 
tions was evident. 2. Upon the fact that it often 
accompanies strabismus and other deformity, man- 
festly due to convulsive action, in different parts of 
the system. 

In confirmation of this position he offers, with 
other evidence, the following remarkable" observa- 
tion. Twin infants were affected with double con- 
genital club-feet, which at the end of six months 
had assumed a natural position, under treatment. 
At this time, one of the infants was seized with 
convulsions, accompanied with a return of the club- 
feet, which were treated anew with success. At 
the end of a year, fresh convulsions occurred, and 
the distortion was again reproduced in one of the 
feet, though in a less degree. 1 

An unequal pressure of the uterus has been as- 

1 Etioloorie Generate des Pieds bots congrenitaux. 1843. 



CAUSES. 83 

signed as a cause of fetal distortion ; but this ex- 
planation admits of doubt. The presence of the 
water of the amnios would tend to counteract such 
pressure ; upon which ground Breschet rejects the 
theory, while Guerin, on the other hand, maintains 
that a certain lateral, but uniform flattening of the 
foot, may result from this force. Duval offers a 
number of observations, tending to show that cer- 
tain positions of the child during uterine life, may 
induce deformity. In these observations, the club- 
foot was accompanied by distortions, which were 
evidently exaggerations of the natural position ; 
such as a permanent folding of the arms, the thighs 
being flexed upon the pelvis. They seem rather to 
indicate a general tendency to muscular contrac- 
tion, than a distinct cause of the development of 
club-foot. 

c. Guerin discards the doctrine of an arrest of 
developement, advanced by Breschet, as an original 
cause of distortion, but admits the influence of this 
principle as a consequence and aid of muscular 
retraction. 

2. Consecutive. These sources of distortion are 
more readily appreciated. Among them are, 
wounds of the leg or plantar surface, blows and 
sprains. That variety which results from wounds, 
or from disease of the bones, generally bears marks 
of the lesion which has provoked the deformity ; 
and cicatrices and contractions of the integuments, 
supply the place of the distinctive marks of re- 
traction. 



84 CLUB-FOOT. 

It is generally allowed that the paralysis of cer- 
tain muscles may produce distortion, by permit- 
ting the unopposed contraction of the antagoni- 
zing muscular forces. The subsequent transform- 
ation of these muscles, then permanently confines 
the limb in its new position. The majority of 
operators advocate tenotomy in such cases, when 
the distortion materially interferes with the con- 
venience or comfort of the patient. The deviation 
once corrected, the traction of the healthy muscles 
may be counteracted, and the normal position main- 
tained, by springs, or other mechanical contrivances. 
In this way the condition of the patient is often 
very considerably improved. 

Both in the congenital form, and in chronic cases 
which result from spasmodic action, occurring at a 
period subsequent to birth, we meet with the con- 
ditions of retraction before described. The mus- 
cular fibre has given place to a more or less fibrous 
tissue. It has become pale and atrophied ; its 
developement has been arrested, and the points of 
its insertion are approximated. Beneath the in- 
teguments, are found a series of tense, salient cords 
corresponding in position to the tendons, and es- 
pecially evident, when an effort is made, to restore 
the foot to a normal position. 

VARIETIES. 

Most authors recognise three varieties of club- 
foot ; viz : Equinus, Varus, and Valgus. 



VARIETIES. 85 

1. Eqainus. When the heel is drawn towards 
the calf, and the patient walks upon the toes or 
metatarsal extremities, like the horse, which gives 
the name to the distortion. 

2. Varus. When the plantar surface is turned 
inward, and the limb rests upon the outer edge of 
the foot. 

3. Valgus. When the sole is directed outward. 
To these are added a rare variety called Talus. 

Here the toes are drawn upward, upon the front of 
the leg, while the heel alone remains upon the 
floor. It is directly opposed to Equinus. 

Modern writers have proposed other divisions. 

Duval proposes the general term strephopodie 
(oTQi-cpw-Tzovq) for deviation of the foot, and varies 
its application by the insertion of the prepositions, 
tvdov, ££co, vno, a^co, jcdrcu ; — thus streph-endopo- 
die, — exopodie, — ypopodie, — anopodie, — ocato- 
podie, for deviation inward, outward, under, up- 
ward and downward. 

The division of Bonnet is more worthy of atten- 
tion. He divides 1 club-feet into two classes. 

1. Those forms produced by the retraction of 
muscles supplied by the external popliteal nerve. 

2. Those produced by the retraction of muscles, 
to which the internal popliteal nerve is distributed. 
Thus the internal popliteal club-foot includes the 
varieties Equinus and Varus ; while the external, 
much less frequent, consists of the different degrees 
of Valgus and Talus. 

i Sect. tend. 1841, p. 432. 



86 CLUB-FOOT. 

The amount of distortion is marked by degrees. 
Thus Dieffenbach divides each of the three ordinary 
varieties into five degrees. Phillips and Guerin 
into three. Bonnet subdivides his two varieties, 
each into five degrees. 

I adopt the most familiar classification, and shall 
describe three degrees f each form of the affec- 
tion. 

EQLINUS. 

The first degree of equinus, consists of a direct 
elevation of the heel from the floor, due to the gas- 
trocnemii. In the second, this action is exagge- 
rated, and often complicated by the action of other 
muscles. In the third, the toes are bent backwards 
under the foot, and the bony frame-work is more 
or less distorted. 

First Degree. The subject walks upon the ex- 
tremity of the affected foot, of which the toes are 
more or less extended towards a right angle. The 
calcaneum is carried upward, and the astragalus 
slightly dislocated forward. The retracted muscles 
are those attached to the tendo-Achillis, and occa- 
sionally the extensor of the great toe. The foot 
is slightly arched, and shorter than its fellow. It 
presents upon its plantar surface two callosities, cor- 
responding respectively to the heel and ball of the 
foot, the latter being well developed. The toes 
are elevated, partly by the weight of the body, and 
partly by the contraction of their tendons. 



EQUINUS. 87 

Second Degree. The mode of walking is an 
exaggeration of the last ; the foot often inclining to 
one or the other side, when the muscular tension is 
unequal. The skeleton presents a similar position 
of the calcaneum and astragalus, the former of 
which sometimes touches the tibia, while the ex- 
tension of the toes, throws the weight of the body 
upon the articulating extremities of the metatarsals. 

Besides the retracted muscles of the calf, the 
extensors, and in some cases the flexors of the toes, 
begin to appear beneath the integuments. The 
foot is shorter and broader, the heel and toe being 
drawn together, as Guerin supposes, by the retracted 
fibres of both surfaces. Hence also its arched form. 
The great toe is occasionally raised by its own re- 
tracted tendon, while the other toes are sometimes 
flexed upon themselves, in their position of exten- 
sion. The skin of the plantar surface is wrinkled, 
and presents a rough callus at the metatarsal ex- 
tremities. That of the heel, if it no longer touches 
the ground, becomes smooth and delicate. 

Third Degree. As the contraction increases, 
the extremity of the foot gradually passes beyond 
the perpendicular. The toes are directed back- 
ward, until the dorsal surface is beneath, and plays 
the part of the sole. At this period, it is rarely 
uncomplicated with one of the other varieties. The 
bones yield to the forcible retraction of the muscles, 
and to the superincumbent weight. The metatar- 
sals are curved backwards, and slightly separated 
from the cuneiform bones. The ligamentous artic- 



88 CLUB-FOOT. 

illations of the tarsus become lax, and the astrag- 
alus is almost entirely dislocated. 

The gastrocnemii, the flexors and extensors of 
the toes, and the plantar aponeurosis, are concerned 
in this degree of equinus. Lateral complications 
involve other muscles. The foot has become great- 
ly distorted. The skin of the sole is thin, while 
that of the inverted upper surface has become hard 
and rugous. Flexion and extension are prohibited, 
and the arched instep exhibits in its cavity the sa- 
lient and retracted fibres. The toes are often inter- 
laced, the calf much reduced in size, and the knee 
somewhat flexed. 

VARUS. 

The turning inward of the foot, is characteristic 
of this complex form. 

In the first degree the inner edge of the foot is 
raised from the ground. In the second, the patient 
walks upon the outer edge, while in the third, the 
sole is directed upwards, and the dorsum fulfils the 
functions of a plantar surface. 

In simple varus, the foot is raised upon its exter- 
nal edge, while the sole, looking inwards, is directed 
forwards and backwards. It is rare. Guerin ob- 
served but seven cases in four hundred club feet ; or 
less than two in one hundred. l It is more frequently 
complicated with equinus ; which has led the same 

1 Mem. sur. les Difform. du Corps Humain. Paris, 1843, p. 320. 



VARUS. 89 

author to make the divisions of varus, varus equinus, 
and equinus varus, as the one or the other variety 
predominates ; each of the two last being subdivided 
into three degrees. The inward inclination of the 
foot, is sometimes due to the unaided action of the 
gastrocnemii, but more commonly results from the 
traction of other muscles. 

The distortion of the skeleton may be resolved 
into two elements ; adduction and extension. 

Adduction. The astragalus forms a centre, for 
the movements of the calcaneum and scaphoid 
bones. The cuboid moves upon the calcaneum, 
the cuneiform upon the scaphoid, while the toes 
follow the cuneiform in their progress inward. The 
calcaneum presents its inferior face to the opposite 
foot, but its attachments to the astragalus undergo 
little modification. The cuboid is carried inward 
wdth the scaphoid, and exposes a small portion of 
the surface by which it is articulated with the cal- 
caneum. The scaphoid undergoes a more consid- 
erable displacement. It is even partially dislocated. 
Passing inside the head of the astragalus, and de- 
scending from its upper part, its position is oblique. 
The head of the astragalus, at its external and 
upper part, is salient beneath the integuments, while 
a new articulation is formed upon its internal sur- 
face. 

Extension. The pulley glides through its socket, 

and is exposed in front of the tibia and fibula. A 

number of new articulations result from this forced 

extension. The scaphoid, at its superior internal 

12 



90 CLUB - FOOT. 

part, comes in contact with the internal malleolus. 
Behind, the tibia, and finally the fibula, are articulated 
to the calcaneum. The displaced articular surfaces 
become gradually ossified. The head of the astrag- 
alus is depressed internally, and the anterior facette 
of the calcaneum, absorbed upon its internal surface, 
becomes oblique. 

The walk, in varus, is difficult. In the exagge- 
rated form, the patient often requires a crutch or 
cane. The skin of the dorsal surface, before it ac- 
quires a power of resistance, often takes on inflam- 
matory action at its point of contact with the 
ground. The knees are inclined inward, and the 
affected foot swings over its fellow, or describes 
curves to avoid it. The muscular action is compli- 
cated. The elevation of the heel is due to the 
muscles of the calf. The chief agents of adduction 
are the tibiales, posticus, and anticus. As the foot 
deviates inward, the tendo-Achillis begins to act in 
the chord of the arc described by the leg and heel, 
and exerts an important influence in adduction. 
The flexor of the great toe now begins to draw, 
and the foot yielding to the combined action of this 
muscle and the flexors of the sole, curves upon itself. 
In other cases, the common flexor of the toes, and 
the adductor of the great toe, are refracted, and 
both the flexors and extensors of the foot, acting as 
adductors, from the change in the direction of their 
insertions, promote the distortion. The curve of 
the foot is aided, in this position, by the retraction 
of its dorsal muscles and the plantar aponeurosis, 



VALGUS. 



91 



while the tension of the long peroneal, compresses 
it laterally. 

In its later stages, this variety yields with dif- 
ficulty to surgical treatment. The relations of the 
bones are much altered, and the shape of the foot 
is sometimes little modified after section of the ten- 
dons. In cases of extreme distortion the foot re- 
sembles a huge fist. The toes are flexed and inter- 
laced, and the dorsal surface, if in contact with the 
ground, is occupied by a rough callus. Large and 
remarkable bursse are sometimes found under the 
cuboid bone, when the deformity has existed for a 
series of years. * The now delicate skin of the sole 
is much wrinkled ; the leg is more or less atrophied, 
and often permanently flexed upon the thigh. 

VALGUS. 

This form, in which the sole is turned outward, 
is opposed to varus. 

The first degree, is what has been called flat foot, 
and is characterized by obliteration of the arch, 
with occasional retraction of the extensors of the 
toes. 

In the second degree, the sole is raised from the 
ground, and the w T eight of the body is thrown upon 
the inside of the foot. 

The third presents different characters, due to 
the retraction of different muscles. The relations 

1 Liston on diseases of the Bursae. Lancet, Oct. 21, 1843. 



92 CLUB-FOOT. 

of the bones of the tarsus and metatarsus are 
altered. 

First degree. The skeleton is little modified. 
The ligaments and muscles which unite the ex- 
tremities of the arched sole, are relaxed, while in 
some cases, the retraction of the extensors aid in 
elevating its anterior extremity. The foot is close- 
ly applied to the ground, and rotated outward. 

Second degree. The astragalus is partially lux- 
ated backward, and the cuboid and scaphoid dis- 
placed externally. The peroneals and extensors 
of the toes raise the outer border of the foot, the 
anterior part of which is carried upward and out- 
ward, the toes being elevated by their extensors. 
Third degree. The scaphoid sometimes aban- 
dons the internal surface of the head of the astrag- 
alus, which then becomes inarticular. The bones 
of the tarsus separate one from another, yielding to 
the retracted muscles. The peroneals, the exten- 
sors of the toes, the abductor of the little toe, and 
the accessory muscles are retracted. The metatar- 
sals sometimes leave the anterior articulating fa- 
cets of the cuneiform, to take a position upon their 
superior surface, at an acute angle with the leg. 

If the tendo-Achillis be also contracted, the pa- 
tient walks upon the central portion of the sole, 
with the heel and toes raised. In this exaggerated 
form, a small surface is applied to the ground, and 
the skin not unfrequently becomes inflamed and 
ulcerated. The form of the foot varies with the 
permanent forces applied to it. 



TREATMENT WITHOUT SECTION OF TENDONS. 93 

It is difficult to imagine that the unaided muscles 
of the external surface of the leg, should overpower 
the force exerted by those of the inner side. Gue- 
rin affirms that a pronounced valgus is an indication 
of a more or less complete paralysis of the gastroc- 
nemii, tibiales, and flexor of the toes. Mr. Little 
suggests that another reason for the greater fre- 
quency of varus, is the fact that the flexors and ad- 
ductors are earlier developed in the foetal state, than 
the extensors and abductors. 

TALUS. 

Talus is a name applied to a rare deformity 
nearly allied to the last, and directly opposed to 
equinus. The foot is in forced flexion ; and the 
pulley exposed posteriorly. The retracted muscles 
are those of the anterior part of the leg and dorsum 
of the foot. According to Guerin, this affection 
also implies a paralysis of the antagonizing muscles. 
The toes are in contact with the front of the leg, 
and the weight of the body is thrown upon the heel. 

In all these forms, the original distortion is rather 
due to the muscles than to the aponeuroses and 
ligaments, which undergo subsequent retraction. 

TREATMENT WITHOUT SECTION OF TENDONS. 

Before the introduction of the subcutaneous ope- 
ration, it was common to treat club-foot by the 
unaided force of machines. Although this princi- 



94 CLUB - FOOT. 

pie is still maintained by certain orthopedists, it 
cannot be deduced from a scientific consideration 
of the subject. It is now a well established fact, that 
in certain cases of distortion, the tissue of the short- 
ened muscles undergoes a fibrous transformation ; 
and it is highly probable if not equally certain, that 
this transformation is in proportion to the degree of 
tension to which the muscular substance has been 
subjected. In an old case of varus, for example, the 
leg and foot form a sort of bent bow, of which the ex- 
tremities are united by a cord of fibrous tissue, which 
at once becomes tense, when an attempt is made to 
straighten the limb. It seems obvious, that the first 
step towards straightening the bow, is to sever the 
string which aids in keeping it flexed ; and this 
treatment is in fact indicated, unless it can be 
shown, either that the operation is attended with 
danger or inconvenience to the patient, or that 
unaided mechanical treatment is equally efficacious. 

Now it is well known that the subcutaneous divis- 
ion of a tendon, when properly performed, is attend- 
ed with trifling pain, and that there is little or no 
chance of subsequent inflammatory accidents. On 
the other hand, very severe pain often accompanies 
the attempt to elongate a retracted tendon by simple 
extension. And while few at the present day will 
dispute, that the time occupied by this process is 
much longer, the deformity is liable to re-appear at 
a subsequent period. 

It is not here implied that all cases of distortion 
demand an indiscriminate division of tendons. On 



TREATMENT WITHOUT SECTION OF TENDONS. 95 

the contrary, there are certain cases of recent de- 
formity, and of disease originating in the joint and 
not in the muscles, where the tenotome may not be 
required. In such cases the surgeon should be 
guided by a knowledge of the original lesion and 
its effects. If, however, a single rule were required, 
applicable in a large majority of cases, it should be 
the following : When in distortion of long standing, 
while a certain degree of motion still remains in the 
joint, a tendon evidently hinders the limb from assum- 
ing a normal position, it should be divided. 

Upon this subject Bonnet (de Lyon) thus re- 
marks : 1 " Among children it is often possible to 
cure club-feet by machines alone, by friction, etc. ; 
but as, in easy cases, the section of the tendons in- 
sures success, abridges the treatment, and avoids 
pain ; as it is, besides, perfectly innocent, I believe 
that recourse should always be bad to it, unless 
children are to be treated during the first months 
which follow their birth. It is then so easy to bring 
the foot into the normal position, that friction and 
machines, which, at a more advanced period of life, 
are only accessories of treatment, are then its prin- 
cipal feature, and are alone adequate to produce the 
desired effect." 

The same distinction is made by Guerin, be- 
tween the treatment of the conditions of contraction 
and retraction. 2 

1 Traite des Sections Tendineuses, etc. Paris, 1841, p. 567. 

2 Vues Generates, 4-c. Paris, 1840, p. 73. 



96 CLUB-FOOT. 

" Simple contraction permits us to hope for the 
immediate elongation of the muscles, by means 
proper to effect it ; extension, kneading, (massage) 
frictions, &c. ; while veritable retraction, shorten- 
ing with fibrous degeneration, implies the impos- 
sibility of a return of the muscles to a normal length, 
or the impossibility of a sufficient mechanical elong- 
ation, and demands in consequence the aid of a 
cutting instrument. Thus, recent deformities by 
contraction, torticollis, flexion of the limbs, may be 
often successfully treated by mechanical and medi- 
cal agents, w r hile old deformities by retraction de- 
mand, peremptorily, surgical means." 

For simple mechanical treatment, different meth- 
ods have been devised. 

In the apparatus of Venel the action is lateral. 
In varus, for example, upon the external side of the 
leg, and the internal surfaces of the foot and heel. 

Delpech employed two machines ; the first, to 
bring the foot straight, the second, to attain the 
horizontal position. 

Dieffenbach and Guerin have employed plaster 
for the same purpose. The foot placed in a box, 
is brought as far as possible towards a normal posi- 
tion, and covered with plaster, which is allowed to 
set. It is subsequently renewed at intervals of two 
or three weeks. A small hole broken in the mass, 
exhibits the condition of the tissues during treat- 
ment. Guerin especially recommends this method, 
when the delicate and irritable skin of young sub- 
jects, refuses to submit to the pressure of bandages. 



SECTION OF TENDONS IN CLUB-FOOT. 97 

The force is equally distributed, while the cuticle is 
softened by the retained transpiration. 

Mechanical aid is occasionally useful, for the pur- 
pose of rendering the tendon tense and salient 
before section. The apparatus requires continued 
care, and frequent re-application, especially in 
infants, where the tissues, compressed by the straps, 
diminish in volume, and the foot becomes loose. 

SECTION OF TENDONS IN CLUB-FOOT. 

Different varieties of the deformity demand the 
section of different fibrous fasciculi. 

For the elevation of the heel, the tendo Achillis. 
For the foot raised upon its outer edge, the tibialis 
anticus ; turned upon its internal edge, the pero- 
neus tertius, and all or part of the extensors of the 
toes. For adduction, the tibialis posticus, for ab- 
duction, the peronei longus and brevis. 

For the curvature of its internal border, the ad- 
ductor of the great toe. For the permanent flexion 
and extension of the toes, their corresponding mus- 
cles, both long and short. And finally, when acces- 
sory to the distortion, the plantar aponeurosis, and 
any of the tendinous and muscular fibres of the foot 
and leg. 

For the different varieties of the distortion, M. 
Guerin has commonly divided the tendons as fol- 
lows. For equinus, the tendo Achillis, and some- 
times the flexor proprius of the great toe. For 
pure varus, the tendo Achillis, and tibialis posticus. 

13 



98 CLU3-F00T, 

For varus-equinus, the tibiales anticus and posti- 
cus, the tendo Achillis, the extensor proprius and 
adductor of the great toe, and sometimes the pero- 
neus longus. For valgus, the peroneus tertius, and 
the longus and brevis. For talus, the tibialis anti- 
cus, the peroneus tertius and the common extensor 
of the toes. And finally, the plantar aponeurosis ; 
and other muscles, in less common varieties. 

Before the volume of Bonnet, (de Lyon,) pub- 
lished in 1841, I believe no writer had minutely 
described the manner of dividing the different ten- 
dons of the leg. Operations upon the tendo Achil- 
lis and tibialis anticus, were already the subject of 
various memoirs ; but the tibialis posticus, and the 
peroneals of the ancle, had not at that time been 
divided upon the living subject, although their posi- 
tion was indicated by Velpeau, with a view to their 
section. Duval in his second edition published in 
1843, gives certain details upon this point. 

The manual of the subcutaneous operation has 
been before indicated in general terms. The ten- 
don is made salient if possible. A fold of skin be- 
ing pinched up at one end, between the thumb and 
finger of the operator's left hand, the other end is 
confided to an aid, and the tenotome introduced by 
a simple puncture at its base. The fold is released 
that the puncture may recede to a distance from 
the point of section, and the tendon is divided by a 
sawing motion. 

Tendo Achillis, The patient commonly lies upon 



SECTION OF TENDONS IN CLUB-FOOT. 99 

the belly, though Dieffenbach prefers a kneeling 
position. 

The place of section is of importance. Duval 
and some other writers, merely indicate a point an 
inch or two above the calcaneum. The distance 
evidently varies with the dimensions of the limb, 
and certain other considerations, but as a general 
rule, the most salient point should be preferred. 
While the muscular fibres are to be avoided, above, 
the want of vitality in the tissues forbids a section 
too near the bone of the heel. 

When the tendon is contracted, it sometimes ap- 
proaches the posterior tibial artery and veins, which 
we avoid in receding from the heel. 

Scoutetten describes a bursa mucosa near the cal- 
caneum, the puncture of which might liberate the 
synovial secretion, in sufficient quantity to interfere 
with re-union of the tendon. 

Authorities are divided upon the direction of the 
section. Stromeyer, Scoutetten, Duval, cut from 
the bone towards the surface ; while Bouvier, 
Dieffenbach, Guerin, and many other surgeons, 
enter the knife beneath the integuments, and in- 
cise toward the bone. It is, in general, a matter 
of little importance whether the section be com- 
menced upon the anterior or posterior surface of 
the tendon. When, however, the tendon so nearly 
approaches the posterior tibial artery, with its ac- 
companying veins and nerve, that it is difficult to 
engage it alone upon the blade, it is evidently bet- 



100 CLUB-FOOT. 

ter to cut toward the bone, that the edge may repel 
the yielding vessels. 

If a pointed tenotome be employed, it should be 
hindered from piercing the integuments of the op- 
posite surface. The safest plan is to employ a blunt 
tenotome, a puncture being first made with a lan- 
cet or pointed knife. 

Most surgeons prefer to make this aperture upon 
the inside of the heel ; a preference for which no 
strong reason is offered. The integuments are 
somewhat more lax, and the tendon is occasion- 
ally more voluminous, upon that side, while the 
slender tendon of the plantaris is there more directly 
beneath the instrument. 

A fold of the integument being pinched up, and 
the tenotome being introduced at its base, the foot 
is extended by the operator, and the tendon, when 
tense, severed by an alternate movement of the 
blade. The moment of section is accompanied 
with a noise, and with the separation of the extrem- 
ities in most cases, although the bones are some- 
times so distorted, or other tendons so retracted, 
that this separation is inconsiderable. The air be- 
ing carefully excluded, and the blood expelled, as 
far as practicable, the wound is closed with adhe- 
sive plaster. 

The division of other tendons may precede or 
follow that of the tendo Achillis. Velpeau divides, 
in the same operation, all the retracted tendons. 
Phillips, Duval and others, seek to reduce the com- 
plicated varieties of the deformity to the simple 



SECTION OF TENDO>- IN CLUB-FOOT. 101 

form of equinus, for which the tendo Achillis is 
subsequently divided. Both methods recommend 
themselves by their results, but the latter is more 
generally adopted. 

Tibialis Anticus. This muscle is best divided 
at its most salient point, a few lines below the an- 
nular ligament. Beneath, is the articulation of the 
astragalus with the tibia and fibula, which might 
be endangered by too deep a section. M. Bonnet 
asserts that the division of the tendon of the heel 
often relaxes this tendon, and obviates the neces- 
sity of its section. 

Tibialis Posticus, Certain cases of exaggera- 
ted distortion, have been supposed to demand the 
section of this tendon, though the operation is com- 
paratively rare, and of difficult execution. Behind 
the tibia, it is enclosed in a sheath, in the neigh- 
borhood of an artery of considerable size. Some 
anatomical knowledge is required to reach its posi- 
tion below the ankle, since it is rarely salient, and 
its section is unattended with perceptible separa- 
tion of its extremities. In cases of complicated 
equinus, when the scaphoid is at a distance from 
the external malleolus, the following method of M. 
Bonnet may be adopted. The eminence of the 
head of the scaphoid being found, the tenotome 
is entered at a quarter of an inch above, and a lit- 
tle in front of it, and advanced till it meets the 
astragalus. The instrument is then slid along 
against the bone, until its extremity arrives at a 
point four or five lines beneath the prominence of 






102 CLUB-FOOT. 

the scaphoid. If the edge of the tenotome be now 
raised until it reaches the skin, the tendon is with 
certainty divided. This method is inapplicable in 
the more marked degrees of varus. 

The extensors of the toes should be severed at 
their most prominent point, commonly at the artic- 
ulation of the metatarsals with the phalanges. 

Peronei longus and brevis. These tendons are 
enclosed in a fibrous sheath, above or below which 
they may be divided. Above, they are occasion- 
ally quite prominent. The position to be chosen 
below, is about half an inch in front of the ankle, 
and as was indicated for the tibialis posticus. The 
surest method consists in introducing the pointed 
tenotome behind the tendon, and cutting from 
within outward. This point less endangers the 
articulation, and allows the instrument to pass free 
of a protuberance situated upon the external side 
of the calcaneum. 

Flexor communis and flexor longus pollicis : 
The depth of these tendons renders their section 
difficult, elsewhere than on a line with the first 
phalanges of the toes. 

The blade is slid beneath, and advanced to the 
surface. The short flexors may be included in the 
section. 

The Plantar Aponeurosis is often retracted, and 
requires division. The tenotome should be intro- 
duced at the inner edge of the foot, where the 
fibres are in strong relief; commonly at a point 
near the articulation of the first with the second 



MECHANICAL TREATMENT. 103 

range of the tarsus. The section should not be 
carried so deep as to wound the articulation. This 
is perhaps the most painful of these operations. 

The narrow blade being carefully withdrawn 
without enlarging the puncture, the blood and any 
accidental bubble of air are expressed. The finger 
is kept upon the wound, until a bit of adhesive plas- 
ter is made ready and applied, so as hermetically 
to seal the orifice. 

The foot may be then enveloped for an hour or 
two with a wet compress, which relieves a local 
burning pain, sometimes experienced by the patient. 

A re-division of the tendon is occasionally re- 
quired during the mechanical treatment, and is in- 
dicated by the resistance and prominence of the 
tendon. 

In this way the tendo Achillis has been unjusti- 
fiably divided, upwards of twenty times upon the 
same individual. 

A twice or thrice repeated section is not uncom- 
mon, nor is it objectionable. 

The new division should be effected a short dis- 
tance above the cicatrix, which occupies the posi- 
tion of the previous section. 

MECHANICAL TREATMENT. 

It has been a question, whether force should be 
immediately applied after the section of tendons, or 
whether it should be delayed to a subsequent period. 
Velpeau gives preference to immediate mechanical 



104 CLUB-FOOT. 

treatment. Duval, while he recommends the foot 
to be at once placed in a machine, to retain any 
advantage that may have been gained by the sec- 
tion alone, deprecates immediate extension. I be- 
lieve that many of the inflammatory accidents so 
frequently reported as results of tenotomy, are to 
be attributed to a too hasty application of force. 
It may be asserted that a large majority of Euro- 
pean orthopedic surgeons, follow the example of 
Stromeyer, and wait for the cicatrization of the 
puncture, before applying extension to the limb. 
In this country, this practice was recommended by 
Dr. Hayward, 1 of Boston, as long since as 1841. 

At the end of forty-eight, seventy-two hours, or 
even a much longer period, when the integuments 
are united, and the tendon has set up a restorative 
process, force may be gently applied. 

The adjustment of a machine requires much 
immediate and subsequent care. A gradual and 
long continued force, alone will induce the foot to 
resume its normal position. The foot is unequally 
covered with tissues, and a slight pressure, even of 
a strap, a lump of cotton, or a fold of bandage, be- 
comes painful where the bone projects. This is 
especially true of thin subjects. 

The pain is in general dull, though sometimes 
insupportable. In equinus the great toe and in- 
step are more frequently the seat of pain, while in 
the treatment of varus it occupies the external 

i Bost. Med. and Surg. Journal, 1841, p. 313. 



MECHANICAL TREATMENT. 105 

border of the foot ; is lancinating, and exacerbated 
by the warmth of the bed. 

If the pressure be continued, the skin becomes 
red, hot, and exhibits a gangrenous vesicle, fol- 
lowed by slough and ulceration. At other times 
the foot is much swelled, while the limb, especially 
in scrofulous subjects, becomes more or less cede- 
matous. 

When the pain is local and permanent, the appa- 
ratus should be removed, and the skin, if red, 
soothed with emollient and narcotic lotions. At 
the end of a few hours, the machine may be re- 
applied, the spot being well protected with cotton. 
In case of an eschar, the ulcer should be allowed to 
heal, before any attempt to re-commence mechani- 
cal treatment. 

The first application of a machine is always in- 
effectual. The tissues require time to accustom 
and adapt themselves to their new position. They 
are impatient of force, or are so depressed, that 
the foot becomes loose in the machine. When it 
is necessary to change the apparatus, it is impor- 
tant to maintain the foot in its new position during 
the process. If allowed to escape from the hand 
for a moment, it tends to resume its recent form, a 
movement accompanied with great pain. The 
part should be kept cool. During the first ten or 
twelve days, it is well to examine the apparatus 
once or twice a day. It is better also to increase 
extension in the morning rather than the evening, 
when the consequent pain sometimes hinders the 

14 



106 CLUB-FOOT. 

patient from sleeping. A want of attention to 
these details may involve the necessity of suspend- 
ing the treatment, when the progress of several 
days is sometimes lost in a short time. 

MACHINES. 

It remains to describe some of the principal ma- 
chines, employed in the treatment of club-foot. 
The principles and aim of most of them are the 
same. They offer different mechanical combina- 
tions, which belong rather to the mechanician than 
the surgeon. It is this peculiarity, together with 
assiduous care required in the use of the apparatus, 
which has led to the establishment of institutions 
devoted to the treatment of deformity, and has cre- 
ated a class of specialists known as orthopedists. 

The machines may be described as consisting of 
a series of pieces, each adapted to a corresponding 
detached portion of the skeleton, and united by 
joints, the movements of which represent those of 
the articulations. 

The apparatus should be capable of conforming 
itself to the curve of the distorted limb, and is pro- 
vided with screws, or other mechanical contrivances, 
for forcibly restoring the parts to a normal position, 
(figs. 16, 17, 18.) 

EQUINUS. 

When the deviation is slight, it suffices, after 
section of the tendons, to confine the foot in a com- 



EQUINUS. ] 07 

mon boot^the leg of which is of stiff cowhide, and 
laced in front. The starched bandage is also em- 
ployed with success for this purpose. 

If the distortion is great, these methods are in- 
sufficient, and it becomes necessary to employ a 
certain amount of force. The machine of Stro- 
meyer, and the boot of Scarpa, may be regarded as 
the type of such apparatus, and have undergone 
various modifications. 

The Machine of Stromeyer, (fig. 14,) employed 
by Dieffenbach, consists of two bars of wood, ex- 
tending from the ham to the ancle, on each side of 
the leg, and united by cross-pieces at top and bot- 
tom. A third sliding cross-piece, capable of being 
fixed by screws, serves as an axis of flexion and ex- 
tension to a piece of board which corresponds to 
the sole of the foot. The flexion of this wooden 
sole is effected by two cords, which, attached to its 
upper corners, traverse pulleys at the upper part of 
the parallel bars, and return to a roller governed 
by a ratchet, at the lower extremity. The calf of 
the leg rests upon a sheet of leather attached to the 
parallel bars, and is secured by straps. 

Scarpa' } s Boot, (fig. 15,) which has been mod- 
ified by Guerin, Phillips, and others, presents a sort 
of shoe open at top, and united by straps. At the 
ancle, it is articulated with two lateral uprights of 
metal, which are bound to the leg at intervals, by 
wadded straps. The flexion of this joint is gov- 
erned by a screw fixed by its extremity to the sole, 
and passing obliquely to one of the metal uprights. 



108 CLUB-FOOT. 

The sole itself is sometimes jointed, and admits of 
a lateral movement, which accommodates it to the 
lateral varieties of club-foot. It is governed by a 
screw upon its edge. l 

The machine of Stromeyer is possessed of greater 
force than the boot of Scarpa, while the latter is 
more portable. The boot, worn to advantage dur- 
ing the day, may be replaced by the machine of 
Stromeyer at night. 

VARUS. 

The treatment of varus is more difficult, the re- 
sistance of the skeleton in the exaggerated forms, 
being often great. 

In young children, it sometimes suffices to sever 
the tendo Achillis, and apply subsequently the 
starched bandage. For older children, the boot of 
Scarpa may be employed. Phillips, Duval, and 
Little, prefer, when the deviation is great, to attack 
the distortion of adduction, and to convert the form 
of varus into simple equinus, before dividing the ten- 
do Achillis. If this method be adopted, the result 
may be attained in the following way. The leg, 
w 7 hen the punctures are healed, should be enveloped 
in wadding which is confined by a roller, (fig. 19.) 
A long splint, morticed at its extremities, is cush- 
ioned, and applied to the external surface of the 
leg, extending from the knee to about six inches 

1 Modifications of these joints will be found in the drawings. 



VARUS. 109 

below the heel. The superior extremity is fixed 
to the head of the fibula by a band, which, after 
passing through the mortice, is continued around 
the leg to the heel, and starched. The splint be- 
ing thus bound to the leg, its lower and projecting 
extremity serves as a point of attachment to a 
band, which is fixed by several turns to the end of 
the foot, and serves to draw it outward. The 
varus is thus gradually converted into equinus. 

An ingenious method of Dieffenbach, (fig. 20,) 
applies to certain cases of slight deviation. The 
middle of a yard of starched band, looped round 
the inside of the hee], crossed on the outer ancle 
and adhering to the calf, tends to draw the heel 
outward. A similar loop, not starched, is allowed 
to hang loose a few inches below the inner ancle 
and sole, and is bound by a roller to the internal 
surface of the leg. A long splint, terminated by a 
lateral notch, which is engaged in this loop, is now 
bound to the external surface, as high as the knee ; 
and the apparatus is complete. It will be observed, 
that the splint acts as a lever over the outer ancle, 
which serves as its fulcrum, to draw the sole out- 
ward, by means of the loop round its extremity. 
If the patient walks, the splint is driven upwards 
and outwards, and the foot necessarily follows it. 

Among the machines which conform to the devi- 
ation of the foot, that of Bouvier and Duval may 
be mentioned. 

The Machine of Bouvier consists of a jointed 
sandal attached to a lever, which, acting over the 



HO CLUB-FOOT. 

ancle, carries the foot outward, as its superior ex- 
tremity approaches the leg. 

The Apparatus of Duval, (figs. 22, 23,) is com- 
plicated in appearance ; but is little more than the 
sandal of Scarpa's boot, attached by a universal 
joint to a leg-piece. The joint is governed by two 
perpetual screws. An upright, which extends from 
the inner side of the sole to the ancle, is furnished 
with a cushioned metal plate, which may be ad- 
vanced against the heel by screws behind it. (fig. 
22, 6.) 

The apparatus of Little is taken from the Lancet, 
Feb. 24, 1844, and will be readily understood from 
the drawing, (fi^. 21.) 

VALGUS. 

In the simpler forms of valgus, a starched bandage 
sometimes suffices, after section of the tendo Achil- 
lis. If complicated, the splint may be used to re- 
duce it to the form of equinus, as was indicated for 
varus. The splint should here be applied on the 
internal surface of the leg. 

OTHER METHODS. 

The treatment of club-foot by means of a plas- 
ter mould \ has been already alluded to. In the 
less exaggerated varieties of distortion, and espec- 
ially in children, the foot may be gradually brought 
down by a sole, or sort of shoe, attached to bands 
of wrought iron, so thin as to allow of being bent 



GENERAL REMARKS. HI 

to the required position, and stiff enough to re- 
tain it. 

While the common expedients of mechanical 
treatment have been described, it is obvious that its 
purpose may be equally effected by a variety of 
combinations, the details of which are here unne- 
cessary. 

GENERAL REMARKS. 

Before submitting the limb to the action of a 
machine, especially of the more powerful ones, it is 
of great importance that it should be adequately 
protected. It should be enveloped in a soft roller, 
and afterwards covered with cotton, especially at 
the points of puncture. The salient parts being 
then wadded, and the cavities carefully filled, the 
cotton should be kept in place by another roller. 
Any fold or inequality is now to be arranged, and 
the whole covered with a stocking. The limb thus 
swathed is placed in the machine, carefully surround- 
ed with cotton, and the straps successively fastened. 
In general the apparatus should be at first loose- 
ly applied. As the foot becomes accustomed to 
pressure, the straps may be drawn tighter, while 
the force is gently augmented. When the patient 
complains of pain, relief is sometimes afforded by 
loosening the straps and inserting fresh wadding. 
A continuance of the pain, demands that the foot 
should be removed from the apparatus, and the skin 
exposed, with a view to the local treatment else- 
where described. 



TORTICOLLIS. 



The division of the sterno-cleido-mastoid muscle 
with the adjacent integuments, was performed by 
surgeons of the last two centuries. 

The operation bj a simple puncture is of more 
recent date. Dupuytren practised this method in 
1822 ; and in 1826 and 1830, Stromeyer 'and Dief- 
fenbach published similar observations of their own. 
In France, the method was reproduced by Amus- 
sat, Bouvier and Guerin, in the years 1836, '37 and 
'38. The latter writer has since materially modi- 
fied the operation, and has thrown much light upon 
the affection for which it is practised. 



CAUSES. 



The agents of this distortion may be considered 
in two classes. The one including the varieties in 
which the contraction or retraction of the sterno- 
cleido-mastoid muscle, is the chief source of the 



CAUSES. 113 

affection, while to the other are referred all other 
causes. To the former, the operation about to be 
considered, is in most cases applicable ; to the lat- 
ter, much less frequently. 

1 . Among this class are a. caries of the bone ; 
indicated especially by the history of the lesion. 

b. An inflammation of the synovial capsules and 
fibrous tissues of the cervical vertebrae, which Bou- 
vier has called articular torticollis. It is either acute 
or chronic. Distortion results from the long con- 
tinued efforts of the patient, to relieve the tense and 
painful ligaments, by displacing them in a direction 
which the head ultimately retains. 

c. Abscesses and cicatrices in the cervical region. 

d. Tumors and glandular engorgements, so con- 
siderable as to force the head for a length of time 
from its normal position. To this last class Duval 
attributes thirty out of * sixty cases treated by him- 
self, in which the disease was followed in two or 
three months, by permanent shortening of the mus- 
cles. 

e. Paralysis of the muscles of one side, the head 
yielding to the unantagonized force exerted by the 
opposite side. The cervical column is not curved, 
but the last cervical is inclined upon the first dorsal 
vertebra. In efforts to bow the head, the chin flies 
to the paralyzed side. In this form, the distortion, 
if exaggerated, may be partially relieved by a sec- 
tion of the healthy muscle. 

1 Op. cit., p. 513. 
15 



114 TORTICOLLIS. 

2. The principal causes which directly affect the 
muscle are, 

a. Active muscular contraction, with subsequent 
retraction, atrophy and fibrous transformation. To 
this agent, most cases of congenital torticollis are 
due. 

b. Muscular rheumatism of the sterno-cleido-mas- 
toid muscle, and the retraction which may result 
from it. 

c. The action of forceps during labor. The mus- 
cle is torn, and blood effused, much as when sub- 
cutaneously divided. Simple contusion sometimes 
suffices to produce inflammation, followed by re- 
traction. 

The deviation is more frequent to the right than 
to the left. According to Phillips, two-thirds of the 
cases of this distortion due to muscular contraction, 
are directed to this side ; and in connection with 
the last cause of the lesion, it is affirmed that in 
seventy per cent of ordinary labors, the head is 
presented in the first position. 

The form of torticollis, about to be considered, 
recognises muscular retraction as its immediate 
cause. The muscles are either idiopathically affect- 
ed, or are retracted at a period subsequent to the 
original lesion ; so that the head, for a length of 
time displaced, by glandular enlargement or other- 
wise, is retained in its abnormal position by the mus- 
cular fibres, which accommodate themselves to their 
new relations. 



STERNO-CLEIDO-MASTOID MUSCLE. 115 



SYMPTOMS. 

The head deviates in various degrees, to the right 
or left of the normal position. In the exaggerated 
forms, the chin is raised in the air, while the 
head is rotated, and depressed upon the shoulder of 
the affected side. In this situation the face changes 
its expression ; the features of the depressed side 
become in a measure atrophied ; the brow falls and 
the cheek becomes less prominent. 

In the region of the sterno-cleido-mastoid muscle, 
a dense cord is felt, which becomes more promi- 
nent and resisting, if force be applied to the head in 
a direction opposed to its action. 

The shoulder of the contracted side is drawn 
upward and forward, so that the sternum and the 
centre of the thorax, being no longer upon the same 
plane with the shoulder, are apparently depressed. 
Much pain with a sensation of dragging, is some- 
times experienced in the affected side, increased 
by atmospheric influences, after exertion, and in bed. 

STERNO-CLEIDO-MASTOID MUSCLE. 

M. Guerin considers this a double muscle, of 
which the two parts, endowed with different func- 
tions, may be separately affected. 

The following are his propositions : 1 

i Memoire sur une Nouvelle Methode de Traitement du Torticolis 
ancien, Paris, 1843, p. 186. 



116 TORTICOLLIS. 

1. The sterno-cleido-mastoideus consists of two 
distinct muscles, the sterno-mastoideus and the 
cleido-mastoideus. 

2. The sterno-mastoideus and the cleido-mas- 
toideus are possessed of separate functions. The 
first is especially a motor of the head, the other is 
essentially an inspirator muscle. 

3. In torticollis, till now attributed to the short- 
ening of the entire sterno-cleido-mastoideus, the 
sternal portion of the muscle may be alone primi- 
tively affected. 

4. In the treatment of chronic torticollis, due to 
the shortening of the sterno-mastoideus, the section 
of the sternal portion, may suffice for the disappear- 
ance of the essential cause of the deformity. 

The division of the sternal insertion of the mus- 
cle, is in certain cases, followed by a more or less 
gradual restoration of the head to a normal position. 
Such cases are reported by Duval and other writers. 
In other cases it is insufficient, and it is necessary 
to divide also the clavicular portion. Bonnet : re- 
marks that it is far from sufficing in all cases ; and 
that four times out of five, he was compelled to di- 
vide at a later period the clavicular fasciculus, be- 
fore the distortion yielded. 

VERTEBRAL COLUMN. 

The head being carried out of the centre of grav- 
ity, the vertebral column institutes a series of curves 

1 Op. cit,, p. 582. 



TREATMENT WITHOUT SECTION. H7 

with a view of restoring the equilibrium. They 
are of two kinds. The first is general, and is due 
to all the vertebral articulations. 

The second, described by Guerin, is local, and 
occurs at the intervals of the last lumbar vertebra 
with the sacrum ; of the eleventh and twelfth dor- 
sals ; and of the seventh cervical and first dorsal. 
From this inclination of " locality" which is an ex- 
aggeration of the normal movements of the articu- 
lations, results a series of reentering angles, com- 
mon to the spines of all subjects affected with 
chronic torticollis, and continuing after the division 
of the muscles of the neck. 

TREATMENT WITHOUT SECTION. 

Before the disease assumes a chronic form, while 
the muscle is yet in a state of simple contrac- 
tion, the deformity sometimes yields to medical 
treatment ; such as kneading, alternate flexion 
and extension, and friction. M. Guerin especially 
recommends local friction with the tartar-emetic 
ointment ; the developement of the pustules being 
sometimes simultaneous with the restoration of the 
head to a normal position. 

It should be remarked, that the sterno-mastoid 
muscle is not the sole cause of distortion in 
chronic cases. Other cervical muscles participate 
in the affection, and a prolonged treatment is re- 
quired to counteract their efforts, even after the 
division of the fibres of the sterno-mastoid. Neither 



118 TORTICOLLIS. 

is the exaggerated form of distortion completely 
relieved by surgical aid. A certain inclination of 
the head often continues, and the features and 
facial bones, atrophied upon the depressed side, 
rarely regain their normal outline. 

The age of the patient is another important con- 
sideration. M. Bonnet places the limit at fifteen 
years-; after which a perfect restoration of the parts, 
in the chronic form of the lesion, can no longer be 
expected. 

SECTION OF THE STERNO-CLEIDO-MASTOID MUSCLE. 

Before the adoption of the subcutaneous opera- 
tion, it was common to divide the integuments 
transversely ; after which the muscular fibres were 
severed, layer by layer. Such was the operation 
practised by Brodie, Warren, Roux, and others. 
Of late years the subcutaneous method has been 
generally adopted. 

Although the section of one, commonly of the 
sternal insertion, sometimes suffices, it is often nec- 
essary to divide both tendons. Guerin, who for a 
time sustained the former theory, has since divided, 
in many cases, both fasciculi. 

It is usual first to attack the more prominent of 
the two tendons, after which the other becomes 
more tense and may be divided either immediately, 
or at an interval of a few days, as suggested by 
Bonnet. In certain cases the muscle may be divid- 
ed at once. 



SECTION OF MUSCLE. 119 

There has been much discussion upon the mer- 
its of different sections. It has been doubted, 
whether the puncture should be made from within 
outward, and the section from the profound to the 
superficial parts, or vice versa ; and much unneces- 
sary importance has been attached to these differ- 
ences. 

As a general rule, the point of section is at a 
short distance above the sternum. Guerin gives 
the distance of six or eight lines ; Phillips an inch ; 
Duval half or three-quarters of an inch. This 
length evidently varies in different subjects. 

It occasionally happens that the tendon makes 
no prominence near the clavicle, and it becomes 
necessary to divide it at its most salient point, two 
or three inches above. The hemorrhage which 
follows a muscular section is sufficient reason for 
proscribing this point when it can be avoided. The 
section of the superior extremity, has long since 
been abandoned. 

The following are the principal methods : 

Method of Dieffenbach. The patient being seat- 
ed, an aid behind draws the head to the side opposed 
to the deviation, while a second aid depresses the 
elbow and shoulder of the affected side. The mus- 
cle being thus made tense, the operator pinches it 
up between his thumb and finger, and passes be- 
neath it, at a short distance above the sternum, a 
small curved bistoury. When the point is felt be- 
neath the skin of the opposite side, the knife is 



120 TORTICOLLIS. 

slowly withdrawn, and the muscle being pressed 
against its edge, is in this way severed. 

DuvaVs Method. The patient is placed in the 
position just indicated, and the tendon made salient. 
The tenotome is introduced at its posterior surface, 
for the sternal insertion, from within outwards. In 
this case, the surgeon being in front of his patient, 
the right hand is employed for the right muscle, and 
the left hand for the left. For the clavicular inser- 
tion, the knife is introduced behind the most salient 
edge, whether external or internal, and the tendon 
is divided, from the deep to the superficial lay- 
ers. When the tendinous fasciculus is not marked 
beneath the skin, a puncture is made with a lancet, 
by which a blunt tenotome is carried to the opposite 
border of the muscle. 

On three occasions, M. Duval divided the whole 
muscle, by the aid of a single puncture at the inter- 
nal border of the sternal insertion ; and once, by 
a puncture at the external border of the clavicular 
extremity. 

Guerirts Methods. Stemo-mastoid. 1. The pa- 
tient lies upon a bed, the upper part of which is 
elevated. An aid draws the head, so as at once to 
oppose the inclination, and exaggerate the existing 
rotation. In this way the muscle is extended, and 
by the last movement carried into an anterior plane ; 
detached as it were from the subjacent parts. A 
fold is raised parallel with the muscle, and the ten- 
otome introduced flatwise, beneath the skin, at a 
point corresponding, when the skin is relaxed, with 



SECTION OF MUSCLE. 121 

the external border of the muscle, and six or eight 
lines above its insertion. The fold is released, and 
the edge previously turned upward is pressed upon 
the muscle, which is divided. The tenotome here 
employed, is peculiar, and concave upon the edge, 
(fig. 12.) 

2. In the second method, less effectual than the 
last, and less employed, a convex tenotome is intro- 
duced beneath the tendon. A grooved director is 
here objected to, upon the ground that it traverses 
the tissues with difficulty. 

Cleido-mastoid. The muscle being put in ten- 
sion, and a fold raised, the instrument is introduced 
upon its inner border, eight lines above its inser- 
tion, and the division is effected from the skin 
towards the centre ; so that the two insertions may 
be successively severed in opposite directions by 
means of a single puncture in their interval. 

There is little danger of wounding the larger 
vessels, especially in the methods of Guerin. It 
has been shown how the muscle is carried into a 
plane anterior to these vessels. By making the punc- 
ture near the clavicle, we avoid the anterior jugular 
vein in its passage to the subclavian. The primi- 
tive carotid-artery and internal jugular vein are pro- 
tected by the sterno-hyoid and sterno- thyroid mus- 
cles, and correspond in both sections to the base of 
the blade of the knife. In dividing the cleido-mas- 
toid, the anterior jugular, when it exists, may be 
left between the back of the instrument and the 
skin, if the knife be introduced in a position per- 

16 



122 TORTICOLLIS, 

pendicular to the muscular fibres, and not flat- 
wise. 

Should a second section become necessary at a 
subsequent period, certain precautions are requisite. 
The adhesive action and subsequent cicatrix may 
displace the larger vessels, and Duval suggests, that 
an interval of six months should be allowed to 
elapse, before the section is repeated, in order that 
the newly formed substance may completely insulate 
itself from the surrounding parts. 

The complete division of the muscle, in all these 
methods, is attended with a slight explosion, deep- 
ened by the proximity of the chest, and also by a 
sudden separation of the two ends of the divided 
muscle, and a corresponding movement of the head. 
As soon as the knife is withdrawn, the blood is to 
be expressed from the wound, and the puncture 
hermetically sealed with a bit of adhesive plaster of 
the size of a shilling. A compress and roller com- 
plete the dressing. Great care is requisite to pre- 
vent the admission of air into the wound. Pus in 
this region sometimes infiltrates the anterior medi- 
astinum. Once formed, the pus should be allowed 
to escape ; although when fluctuation is just per- 
ceptible, compression sometimes favors the absorp- 
tion of the fluid. For this purpose, a ball of lint is 
placed upon the tumor, and being covered with com- 
presses, is maintained by long strips of adhesive 
plaster, extending from the back upon the chest. 

With a little attention however to diet and repose, 
espscially if the air has been excluded from the 



MECHANICAL TREATMENT. 123 

wound, these accidents are avoided. The wound 
commonly heals by the third day, and mechanical 
treatment may be then commenced. 

SECTION OF OTHER MUSCLES. 

The division of the sterno-cleido-mastoid muscle 
sometimes relieves the deformity but incompletely. 
It is then important to ascertain whether other mus- 
cular fibres aid in retaining the head in its anormal 
position ; in which case they become tense, oppose 
any effort to replace the head, and require division. 
Portions of the trapezius, and platysma have been 
thus divided. 

MECHANICAL TREATMENT. 

The aim of mechanical treatment is twofold. 1. 
To adjust the head in a normal position. 2. To 
correct the curves of the vertebral column. 

When the deformity is slight, the spinal distortion 
is also inconsiderable, and attention should be chiefly 
directed to the position of the head upon the cervi- 
cal vertebrae. In older patients, and in the exag- 
gerated varieties, it becomes necessary to apply 
force to the vertebrae, both in the cervical and dor- 
sal regions. The apparatus is then complicated. 

Among the more simple means of commanding 
the head, are the following : 

1. A cravat of pasteboard, or boiled leather, as 
employed by Guerin, is simple, and almost univer- 



124 TORTICOLLIS. 

sally adopted in ordinary cases. Its height may 
vary at different points. A substitute is a circle of 
stiff wire, so bent as to correspond with the edges 
of such a cravat. 

2. A band carried around the head horizontally 
and united to vertical bands over the crown from 
before backward, and from ear to ear. A band 
fastened to the first, at the mastoid process of the 
healthy side, is drawn down in front and attached 
upon the chest or at the waist, so as to aid the ac- 
tion of the healthy muscle. A cap may be substi- 
tuted for the bands upon the head. 

3. The temporo-axillary bandage of Mayor. The 
base of a triangular handkerchief is applied to the 
temple of the affected side, and the extremities 
brought, one round the forehead, the other round 
the occiput, to be united below the axilla of the 
sound side. A horizontal band may be added to 
this bandage. 

The two last methods tend rather to increase 
than diminish the cervical inclination, and are 
therefore only applicable in slight deviation, or as 
temporary substitutes for other apparatus. 

A complete machine, the force of which is adapt- 
ed as well to the spine as the head, is complicated 
and expensive. Various models have at different 
times been contrived for this purpose. They are 
adapted either to the horizontal or upright position. 
The former have received the name of orthopedic 
beds, and are chiefly modifications of those of Shaw 
and of Guerin. 



MECHANICAL TREATMENT. 125 

The apparatus which admits of locomotion recog- 
nises its leading features in the Minerva of Dela- 
croix, and takes its point of counter extension upon 
the pelvis or the shoulders. 

The Apparatus of Bouvier, modified from the 
Minerva, consists of a wide metallic belt resting upon 
the hips and haunches. To this is fastened a steel up- 
right in the form of a T, which occupies the region 
of the spine and scapulae, and is retained by shoul- 
der-straps. A firm point of counter-extension is 
thus obtained between the shoulders, to which is 
attached an upright bar, from which the head is 
suspended. 

The head is secured by a horizontal metallic 
band, descending upon the mastoid processes, which 
gives attachment to vertical straps for the crown 
and chin. The iron rod by which it is attached to 
the steel plate between the shoulders, is so contrived 
as to admit of elongation, extension, flexion, rota- 
tion, and lateral inclination, in any of which posi- 
tions it may be fixed, (fig. 24.) 

Cravat of Phillips. A large triangular piece of 
sheet iron, well cushioned, is adapted to the back 
of the chest, the base corresponding to the shoulders. 
A strap secures it around the hips. The chief sup- 
port is derived from broad wadded suspenders, which 
secure it over the shoulders. To this triangle is 
fastened an upright of iron, capable of being raised 
or depressed, and terminated above by a tooth, 
corresponding in position, and use, to the odon- 
toid process. Upon this rotates, by means of a 



126 TORTICOLLIS. 

socket, a stuffed collar of iron which supports the 
chin. This contrivance is cheap and effectual, (figs. 
25, 27.) 

The orthopedic bed of Guerin is modified from 
that of Shaw. It consists of the divided bed, of 
which the superior point of division corresponds to 
the union of the cervical and dorsal regions, instead 
of corresponding to the central dorsal region, as in 
that employed for lateral curvature of the spine, 
(figs. 31, 34.) The body is secured upon the bed, 
and appropriate lateral force is applied. The head 
is confined in a casque, and is secured by a collar 
adjusted to the chin. The movements of this hel- 
met, which are thus communicated to the head, are 
universal, and graduated. l 

An inclined plane, to the head of which the chin 
is attached, by a handkerchief passing under it, 
is serviceable in certain cases. Extension is then 
effected by the weight of the body. 

i The details of the machinery, obvious to an ingenious mechanist, 
but requiring a long description, may be found in the last edition of 
Torticollis, Paris, 1843. I am not persuaded that the mechanism is 
the simplest and most effectual. 



FALSE ANCHYLOSIS OF THE 
KNEE-JOINT. 



The division of tendons is much less effective in 
deformities of the knee, than in those of the foot. 
While club-foot depends in a majority of cases upon 
muscular retraction, without lesion of the synovial 
surfaces, distortion of the knee rarely originates in 
this cause. It commonly results from disease, either 
of the cavity of the joint, or of its investing mem- 
branes. Duval refers fifteen cases in twenty to sub- 
inflammations of this articulation. The change in 
the form and character of the tissues is then so 
considerable, as often to render it difficult to restore 
the normal shape of the limb or its functions. Most 
cases, however, are susceptible of amelioration 
from treatment, and it is sometimes possible, both 
to straighten the limb and to renew its suspended 
movements. 



128 KNEE-JOINT. 



CAUSES. 



Congenital retraction. This variety of the affec- 
tion is analogous to other congenital deformities, 
and is accompanied with the fibrous transformation 
of the retracted muscles. As in the operation for 
club-foot, their section then facilitates the subse- 
quent mechanical treatment. Muscular retraction 
materially interferes with the developement of the 
bones and other parts, in early life ; and the limb 
rarely or never regains its normal length and out- 
line, if the operation be deferred till adult age. As 
an idiopathic affection of the knee, it is, however, 
comparatively rare. 

Permanent flexion. In this position of the leg, 
the muscles become, after a time, passively retracted, 
and require, equally, division. It is unnecessary 
here to inquire what agents contribute to this posi- 
tion, so common in chronic diseases of this articula- 
tion. By the flexion of the knee, most of the 
muscles are relaxed ; it is the natural position when 
the patient lies on the side, and the necessary one, 
when the synovial cavity is distended with fluid. 

It is also sufficient to know, that in a large ma- 
jority of cases of long standing, resulting from both 
these causes, adhesions are formed between the 
articulating surfaces ; and in this connection it is 
unimportant, whether they presuppose synovial in- 
flammation, or whether, as Hunter supposed, and 
as seems to follow from the recent investigations of 



PATHOLOGICAL ALTERATIONS. 129 

M. Teissier, 1 a simple state of rest may cause vas- 
cularity of the synovial, and the deposit of false 
membranes. 

Serious lesion of the Joint, The most common 
form of false anchylosis, is that in which the artic- 
ulating surface is materially altered ; where chronic 
inflammation, ulceration and the lesions commonly 
accompanied by the white swelling, have occasioned 
long continued suppuration, cicatrices and change 
in the form of the cartilaginous and bony extremi- 
ites. 

The following are the principal changes which 
result from long continued flexion of the joint, in 
disease of this sort. 



PATHOLOGICAL ALTERATIONS OF THE TISSUES AND THEIR 
CONSEQUENCES. 

The entire limb is commonly withered and atro- 
phied. 

Spontaneous luxation. The weight of the flexed 
leg resting upon the heel in a horizontal position, 
aided by the action of the flexor muscles, incline 
the head of the tibia backward, and the joint tends 
to open behind ; while the distended condition of 
the lateral and posterior ligaments finally permit 
this bone to glide back upon the posterior surface of 
the condyles of the femur, which are often atro- 
phied at that part. 



i Gaz. Med. t. ix.,p. GOO -26. 
17 



130 KNEE-JOINT. 

Rotation. The powerful action of the biceps 
flexor, the shape of the condyles, the disposition of 
the crucial ligaments, and the position of the leg, 
which the patient supports upon the outer side of 
the heel, tend to impress upon it a movement of 
rotation outward, often considerable. Duval refers 
to a case in which the internal condyle of the femur 
was received into the external concave surface of 
the tibia ; there being a semiluxation of the tibia 
upon the femur. These partial luxations according 
to Bonnet, accompany three-fourths of the cases of 
angular anchylosis of the knee. 

Outward luxation of the patella generally accom- 
panies rotation of the tibia. 

Change of form in the articulating extremities. 
The parts in contact undergo ulceration and absorp- 
tion. The pressure of the condyles of the tibia, 
often ulcerated themselves, occasion extensive ab- 
sorption of the posterior part of the condyles of the 
femur, w 7 hich are sometimes excavated to the depth 
of half an inch or more. The pressure of the patel- , 
la upon the external condyle in front, destroys its 
convexity. 

Adhesions. The patella is sometimes glued to 
the anterior part of the femur, and sometimes to 
the interval between the femur and tibia, in which 
case it is impossible to straighten the limb. The 
cartilages of the anterior part of the femur are some- 
times absorbed, and the two bones become inti- 
mately united by fibro-cellular bands, in a way to 
obliterate the anterior half of the cavity of the syno- 



DIAGNOSIS. 131 

vial membrane. 1 Finally, masses of fibrous tissue 
surround the joint, occupying especially the popliteal 
region, where they envelope the vessels and nerves, 
and form a compact mass. A dissection was ex- 
hibited by M. Chassaignac to the Anatomical Society 
of Paris, in which the popliteal artery was so con- 
tracted by these adhesions, and imbedded in them, 
that any attempt at sudden extension of the limb 
must have produced its rupture. 

DIAGNOSIS OF THE DIFFERENT ORGANIC LESIONS. 

While the disease is in an active state, besides the 
constitutional symptoms, the knee is often much 
enlarged ; it may present the peculiar doughy feel 
which sometimes accompanies sub-inflammatory 
action in this region, or may be distended with 
fluid. There is generally more or less pain upon 
movement, however slight. 

When the nerve is retracted, probably by virtue 
of its fibrous sheath, it is of manifest importance to 
distinguish it from the tendons, which present a 
similar elevation in the ham. Their relations, how- 
ever, are different. While the tendons may be 
traced to the condyles of the femur, the nerve trav- 
erses the area of the popliteal triangle and gains the 
space between the condyles. 

The position of the bones is easily detected. The 
luxation and rotation of the tibia is indicated by the 

i Bonnet, p. 560. 



132 KNEE-JOINT. 

corresponding and evident modification of the out- 
line of the limb, and by the outward direction of 
the toe, when the anterior part of the thigh is made 
to look directly forward. 

The absorption or disintegration of the articulat- 
ing surfaces is difficult to be detected, and must be 
inferred from the duration of the disease, the posi- 
tion of the limb and of the patella, and from the 
amount of suppuration. 

The existence of fibrous tissues is to be inferred 
from the resistance of the soft parts and the cica- 
trices of fistulous passages. 

Adhesions are less difficult to be recognised than 
ulcerations of the articulating surfaces. The union 
of the tibia and femur is indicated by the absence 
of all movement. The adhesion of the patella 
should not be confounded with its immobility re- 
sulting from the tenseness of the ligaments when 
the leg is flexed. When the patella is adherent, 
we may always infer the obliteration of the anterior 
part of the cavity of the joint. ■ 

It is however in some cases difficult to distinguish 
true from false anchylosis ; the bony, from the 
fibrous union of the parts. The pain produced by 
the forced flexion of the joint is an uncertain test. 
Perhaps the surest indication that the union is 
false, is the possibility of still producing a cer- 
tain amount of flexion beyond the point at which 
the knee is stationary, and hindered from exten- 

i Bonnet, p. 571. 



DIAGNOSIS. 133 

sion by the retracted muscles. The limb can then 
in most cases be straightened. But when the joint 
is entirely deprived of the power of flexion, it is 
probable that the anchylosis is bony ; and in such 
cases even when the osseous deposit is inconsider- 
able, it is doubtful if the degree of flexion has ever 
been diminished. It is of less importance to dis- 
tinguish true anchylosis, imperfect though it be, 
from the complete fibrous union of the synovial 
surfaces, which sometimes follows rheumatic affec- 
tion, since this lesion also offers serious obstacles to 
mechanical treatment. 

Passive flexion of the joint is sometimes dimin- 
ished or entirely prevented, during the examination 
of the patient, by the active contraction of the mus- 
cles ; so that capability of motion may exist where 
it is not detected. In such cases, if the attention 
of the patient be diverted, the muscles become re- 
laxed, and a certain power of movement is found 
still to exist. As was before stated, it is commonly 
in the direction of flexion ; extension being pro- 
hibited by the passively contracted muscles. In 
examining the limb, the alternate forced movement, 
which stimulates the contraction of the muscles, 
may be replaced, by measuring, as Duval recom- 
mends, the distance between the ischium and heel, 
in each position, the pelvis being fixed. If there 
is a difference in the measurements, the union is 
false. 



134 KNEE-JOINT. 



TREATMENT. 



The treatment of false anchylosis of the knee-joint, 
may be considered under three general heads. 

1. The division of the tendons which oppose ex- 
tension. 

2. The extension of the limb. 

3. The reproduction of its normal movements. 
The evidence of the results of treatment is far 

from satisfactory. Thus, in the serious lesion of 
the joint already alluded to, Bonnet maintains that 
the section of tendons is never practised with suc- 
cess ; Phillips is less decided as to the efficiency of 
treatment, while Duval offers numerous observa- 
tions of distortion from lesion of this sort, accom- 
panied with suppuration and subsequent cicatrices, 
in which treatment produced a straight and service- 
able limb. 

The results of these cases seems to have varied, 
not only with the character and degree of the lesion, 
but with the nature of the mechanical treatment ; 
and it is therefore important to estimate the value 
both of the indications for treatment and of the dif- 
ferent methods of applying mechanical force. 

Of the former, one of the most promising is the pos- 
sibility of still executing a certain degree of flexion. 
Duval does not hesitate to affirm, that by means of 
sub-cutaneous sections, its entire extension can 
always be obtained, provided the anchylosis is 
false or incomplete. But it is evident that without 
the indication afforded by the capability of flexion, 



TREATMENT. 135 

it is difficult, if not impossible, to establish this im- 
portant point. There is little or no recorded evi- 
dence to show that the limb has ever been reduced 
when the joint was entirely destitute of the power 
of motion, that is, of flexion ; while on the contrary 
it frequently happens, that all efforts fail to produce 
any modification in the outline of the limb. The 
cavity of the joint has then become the receptacle 
of organized lymph, which has soldered together the 
articulating surfaces. 1 In time, this lymph is trans- 
formed into bone and the anchylosis is complete. 

But it does not theoretically follow, in the absence 
of facts, that treatment must be unavailing, because 
there is no movement in the joint, even at a period 
when the lymph presents some traces of osseous de- 
posit. Nor are the experiments 2 of M. Bonnet 
upon the dead subject conclusive. The organized 
false membrane, while endowed with vital proper- 
ties, must tend to yield to a permanent and pro- 
portionate force ; to be relaxed by gradual traction, 
and to be absorbed by pressure. In this way, con- 
tinued mechanical force is capable of producing ef- 
fects upon the living tissues, which the passive re- 
sistance of the dead and inert fibres would render 
impossible. In such cases, experiment alone can 

1 I have examined a knee in this state, in which there was no possi- 
bility of producing movement, though as yet no osseous particles had 
been deposited. 

2 In these attempts to straighten the limb, it was found necessary 
not only to divide the tendons and fibrous tissues, but afeo to open the 
joint behind, in order to allow the posterior edge of the articulating 
surface of the tibia to recede from the femur. Op. cit., p. 563. 



136 KNEE-JOINT. 

decide upon the propriety or the capabilities of 
treatment. 

Interarticular adhesions are not the only obstacles 
to the successful treatment of this deformity. An 
equal, and according to some writers, a greater dif- 
ficulty exists in the distortion of the articulating 
surfaces. Nor is the amount of this distortion indi- 
cated by the degree of flexion of which the joint is 
capable ; for, as Duval affirms, the joint may enjoy 
this power to a considerable extent, where the al- 
teration of the articulation is sufficient to interfere 
materially with treatment. When the luxation is 
great, and when the condyles are partially absorbed, 
it sometimes happens that all attempts at extension 
are fruitless ; either because the adhesions are too 
firm to be overcome, or because the patella has en- 
gaged itself between the tibia and femur, and can- 
not be displaced. J 

The condition of the articulation also exercises 
an important influence upon the shape of the limb 
after treatment. This, however, depends not only 
upon the degree of luxation and rotation of the 
tibia, upon the amount of ulceration and absorption 
of the cartilage and bone, but also upon the direc- 
tion and adjustment of the mechanical force em- 
ployed during the treatment. 

The tendency of the tibia to backward luxation 
has been referred to. If in permanent flexion of 
this sort, an extending force be applied to the foot, 

i Phillips, Op. cit., p. 201. 



TREATMENT. 137 

the head of the tibia does not glide forward on the 
condyles of the femur, as in the normal condition 
of the joint, but tends to remain stationary behind it. 
The anterior margin of its articulating surface forms, 
against the femur, a fulcrum by which the posterior 
edge is gradually lifted away from the condyles ; 
so that when the limb is straight, the perpendicular 
of the tibia is behind that of the femur, and the 
weight of the body resting on the femur, bears upon 
a point anterior to the tibia. 

This is the condition of the leg in a large pro- 
portion of the cases mentioned by Duval. Mr. 
Little seems to have obtained better results ; the 
tibia being made to occupy a position more directly 
beneath the femur. The advantage in the treat- 
ment adopted by the latter surgeon, is mainly due 
to the distribution of force in the machines em- 
ployed. While that of Duval merely extends the 
limb, the apparatus used by Little aims both at ex- 
tension and at the reduction of the head of the 
tibia ; which is lifted into its place, by an effort 
applied directly to it. In fact, without this arrange- 
ment, the previously existing luxation is liable to 
be exaggerated, and even to be rendered complete. 

The degree of movement permitted to the joint 
after reduction also depends chiefly upon the de- 
gree of the lesion, but also partly upon the treat- 
ment. In Duval's cases, six patients in ten were 
left with a stiff joint ; but it should be remembered 
that this surgeon considers the treatment complete, 
when the limb is brought down and the patient is 

18 



138 KNEE-JOINT. 

able to rest his weight upon it. Little, on the con- 
trary, here commences a third stage of treatment, 
with the view of re-establishing the movements of 
the articulation ; and he seems, in some cases, to 
have obtained this desirable result. 

When the deformity occurs at an early age es- 
pecially when it is congenital, and depends upon 
muscular contraction, it is of great importance not 
to delay treatment. The retracted muscles pre- 
vent the bones from attaining their normal length, 
and irremediable deformity is the consequence. In 
May, 1838, M. Bouvier exhibited to the Acad, des 
Sciences, a specimen which demonstrated these 
consecutive changes of bones and ligaments, and 
the necessity of early action to anticipate these al- 
terations. 

Duval fixes the average duration of treatment 
at six weeks, and the maximum at three or four 
months ; while Little places the average in adults 
at two months ; a shorter period being required for 
children. The process of restoring mobility varies 
from three months to a year. 

MEDICAL TREATMENT. 

It is sometimes well to fortify the general health 
of the patient, who is often of a scrofulous consti- 
tution ; and also to reduce, if necessary, the local 
inflammation, before submitting the limb to surgi- 
cal influences. 

Duval recommends for this purpose a course 



TREATMENT. 139 

like the following. Salt-water baths every two 
days ; if practicable, in the open air and sun. 
Three or four cups daily of infusion of hops, with 
ten grains of bi-carbonate of soda, or a dozen pas- 
tilles of lactate of iron. Claret wine, diluted with 
infusion of hops at meals. Broiled or roast meat. 
No milk nor fruits. In short, a tonic and anti- 
scrofulous regimen. 

At night, a poultice to the knee, made with a 
narcotic decoction. 

Every morning, on removing the poultice, fric- 
tion of the joint with a bit, of the size of a filbert, 
of the following ointment. 

Simple Cerate g i i 

Bromide of Iron 5 i i 
Extr. Hemlock ) . . . 

Camphor ) 

For the bromide of iron may be substituted eight 
grains iodine, with a drachm of hydriodate of po- 
tassa, if slight irritation of the surface be desired ; 
or 5 i i of the iodide of lead as a simple resolutive 
producing no cutaneous irritation. 

SURGICAL TREATMENT. 

Under this head will be successively considered, 
1. Treatment without tenotomy. 2. The section 
of tendons. 3. Sudden extension. 4. Gradual 
extension after the inflammatory symptoms have 
subsided. 5. Tenotomy and extension during the 
existence of local inflammation. 



140 KNEE-JOINT. 



TREATMENT WITHOUT TENOTOMY. 

What has been already said upon this point, in 
connection with Torticollis and Club-foot, applies 
equally to False Anchylosis. The resistance of the 
muscles, when recently contracted, may undoubt- 
edly be overcome by simple extension. According 
to Little, we may succeed without tenotomy in 
effectually straightening the limb, in a favorable 
case of false anchylosis in the adult, after the lapse 
of five years ; but it is rarely possible in a child, 
unless of very lax fibre, permanently to relieve by 
mechanical means, a severe contraction of similar 
duration. The fibrous transformation is more rap- 
idly effected in children ; partly because the func- 
tions are in general more active, and partly perhaps 
because the muscle is subjected to increasing ten- 
sion, as the bones are developed. 

THE SECTION OF TENDONS. 

The tension of the muscles, and the resistance 
which they offer to extension, is of course the im- 
mediate indication for tenotomy. In the con- 
genital form, tenotomy is especially indicated. 
When the retraction is only passive, and the se- 
quence of permanent flexion, the duration of the 
lesion will give some indication of the probable de- 
gree of fibrous transformation, and the propriety of 
tenotomy. In most chronic cases, extension is 



SECTION OF TENDONS. 141 

facilitated and the treatment is abridged, by divid- 
ing the tendons of the ham ; but the more impor- 
tant element of prognosis, the condition of the 
articulation, must be taken into the estimate, in 
deciding the question of treatment. 

The section of the tendons which oppose the 
extension of the leg, seems to have been first effect- 
ed by Michaelis. 

Dieffenbach operated in 1830, Duval in 1837, 
Bouvier in 1838, and Guerin in 1839. 

The chief varieties in the method of operating 
are those of Dieffenbach and Bouvier ; the former 
of whom divided the tendons from the deep to the 
superficial regions ; the latter in the inverse direc- 
tion. 

Method of Dieffenbach. The patient, supported 
by an aid, is placed upon his knees in a chair, while 
a second assistant confines the thigh of the affected 
side. The operator first divides the tendons of the 
semi-membranosus and semi-tendinosus in carry- 
ing the instrument beneath the skin and beneath 
the tendons. The biceps is divided in the same 
way. The extension is then increased to bring 
into view any fibres which may yet oppose the 
straightening of the limb, and these are successive- 
ly divided. The punctures are carefully closed, 
and the other conditions of subcutaneous wounds 
as far as possible fulfilled. 

Method of Duval. The patient lies upon his 
belly, and the leg is extended. The tenotome is 
introduced at the level and towards the anterior 



142 KNEE-JOINT. 

face of the tendons, the most prominent of which 
is first to be divided. The leg is then farther ex- 
tended, and other tendons become in their turn sa- 
lient. The first is commonly the biceps, the second 
the semi-tendinosus, then the semi-membranosus. 

For the former, the instrument should be intro- 
duced from the hollow of the ham outwards, and as 
far down as possible, to avoid the lesion of the ves- 
sels and nerves. Two punctures suffice ; one for 
the biceps, the other for the two other muscles. 
The knife should not be allowed to perforate the 
opposite surface. It is made to bear directly upon 
the anterior part of the tendon, which is divided 
from its profound to its superficial and cutaneous 
surface. The pain is slight, a few drops of blood 
only escape, and the punctures heal in two days. 

Method of Bouvier. Longitudinal punctures are 
made upon the eccentric border of the tendons to 
be divided. A blunt tenotome is introduced flat- 
wise beneath the skin, while the finger of the left 
hand of the operator apprises him of the progress 
of the instrument. It is then turned upon the 
tendon, which is divided from without inward. 
The edge of the instrument should be so short as 
neither to enlarge with its base the external aper- 
ture, nor in dividing the biceps, to wound with its 
extremity the external popliteal nerve. From the 
puncture of the outer surface the biceps is divided; 
from the internal puncture, the semi-tendinosus, 
semi-membranosus, and if required, the rectus in- 
ternus. 



SECTION OF TENDONS. 143 

According to M. Bonnet, it is necessary in cer- 
tain cases to divide not only the rectus internus and 
sartorius, but the gastrocnemii, which last is effect- 
ed by severing the tendo Achillis. 

From the dissections of this surgeon, it appears 
also that the nerves are sometimes so retracted as 
to resemble tendons. They may be distinguished, 
as was before stated, by their position in the centre 
of the lower part of the popliteal space, from the 
tendons, which pass to a point just inside the con- 
dyles of the femur. 

The larger vessels are deeply seated ; but the 
proximity of the popliteal nerve to the outer ham- 
string is sufficient reason for prefering the method 
of Dieffenbach, which protects it with the back of 
the instrument, to that of Bouvier which exposes it 
to the edge. 

In certain cases, the section of the biceps alone 
suffices, especially in the variety complicated with 
inward deviation ; but it not unfrequently happens 
that the semi-tendinosus and semi-membranosus 
become prominent a week or two afterwards and 
require division. 

From the internal puncture may be successively 
divided the semi-membranosus which is deepest, 
then the semi-tendinosus, and finally the rectus in- 
ternus. Resting here, we avoid the section of the 
internal saphsena nerve, but in dividing the sarto- 
rius, this nerve and vein are necessarily comprised 
in the section. 

It is asserted by Little that it is better to divide 



144 KNEE-JOINT. 

the superficial and cutaneous nervous filaments 
which traverse the surface of the gastrocnemii. 
They may be distinguished from fibrous filaments 
by the peculiar pain, sometimes severe, occasioned 
by their tension, especially during treatment. 

Prof. Froriep of Berlin, reports a case in which 
the fascia lata, and fascia cruralis required division. 
Such cases are comparatively rare. 

MECHANICAL TREATMENT IN THE CHRONIC FORM. 

Two kinds of mechanical treatment have been 
applied to false anchylosis. 

1. Immediate and violent. 

2. Gradual and progressive. 

Among the first are to be ranked the methods of 
DiefTenbach and Louvrier. 

The second includes the methods of Duval, Bou- 
vier and others. 

SUDDEN EXTENSION. 

The method of DiefTenbach diners from that of 
Louvrier. While the former divides the tendons 
and then violently flexes the limb, Louvrier directs 
the effort to its extension, and without section of 
the tendons. In the one case, the punctures of the 
integuments are liable to laceration ; in the other 
the tendons are almost of necessity ruptured. 

Method of Dieffenbach, Immediately after the 
division of the resisting tendons and fibres, and 



SUDDEN EXTENSION. 145 

also of any profound cicatrices which offer impedi- 
ment to extension, the operator places one hand 
upon the thigh of the patient, and with the other 
seizes the foot and forcibly flexes the limb. It is 
then alternately flexed and extended, the principal 
effort bearing upon the flexion. To effect this 
the united force of two or three men is sometimes 
requisite. 

The rupture of the adhesions is attended with 
cracking explosions. The punctures covered during 
the operation by the fingers of the operator, to ex- 
clude the air, are now closed with sticking plaster, 
the limb enveloped in a roller, and placed in a 
splint. 

It sometimes happens that the limb constantly 
returns to a state of flexion after extension ; a 
movement due to the retraction of the lateral liga- 
ments. The external ligament is commonly the 
one affected, and is then perceptible beneath the 
skin, and requires division. 

Method of Louvrier* The barbarous method of 
M. Louvrier needs only an allusion. The limb is 
confined in splints, hinged at the knee. The patient 
is placed in recumbent a position, and forcible ex- 
tension is applied at two points, by means of cords 
wound around a roller. By one the foot is drawn 
down, while the other simultaneously depresses the 
knee towards a straight line. Extension is thus 
effected in twenty-five or thirty seconds ; but not 
without rupture of the skin, and of the tendons of 
the ham, denudations of the vessels and nerves, 

19 



146 KNEE-JOINT. 

gangrene, and in one instance suppuration and 
death the twenty-second day. In another case, 
the artery was ruptured, gangrene ensued, and am- 
putation was rendered necessary. 

The method of Dieffenbach is not exempt from 
these accidents. Duval 1 reports a case of fever, lo- 
cal suppuration and delirium following the operation. 

Such results peremptorily forbid the adoption 
of these methods in chronic cases, especially as 
equal advantage is to be derived from a gradual 
and much less painful application of force. 

In recent cases, of not more than three or four 
months standing, and the result of acute inflam- 
mation, circumstances may render it expedient to 
break the adhesions by sudden force, but even then 
gradual extension is to be preferred in a majority 
of instances. In such a case, when the inflamma- 
tion has subsided, manual force may be applied as 
described by Bonnet. 

For this purpose, the flexors of the leg are re- 
laxed by a horizontal position of the patient. An 
aid confines the pelvis, while another supports the 
foot. The surgeon now with one hand carries 
forward the head of the tibia, to prevent its back- 
ward luxation, while with the other he depresses 
the inferior extremity of the femur. The leg when 
reduced is placed in a hollow splint, and enveloped 
in a starched bandage. 

Slowly progressive extension. In this method, 

l Op. cit., p. 455. 



SUDDEN EXTENSION. 147 

the two portions of the limb are confined in splints, 
hinged at the knee, and brought into a straight line 
by long continued traction or other mechanical 
means. The process is often completed in less 
than a month after the division of the tendons. In 
exceptional cases it requires three or four months. 

In the construction of these machines, care 
should be taken to distribute and equalize the 
force. It has been elsewhere shown, that the tibia 
is disposed to backward luxation, and often re- 
quires to be urged forward at the moment exten- 
sion is applied. Perhaps the best machine is that 
described by Little. The apparatus of Bonnet, 
which resembles the apparatus of Louvrier, and 
imitates the manner already described, of applying 
manual force, is also efficient. 

The punctures are allowed to cicatrize, and the 
limb is well protected with cotton before being 
submitted to the machine. A flannel roller is then 
applied, somewhat tighter at the knee than above 
or below, to aid in counteracting the tendency to 
flexion. Extension at first progresses rapidly, even 
when the flexion is considerable, to the extent of 
thirty or forty degrees in a week ; but is subse- 
quently more gradual and laborious. 

When the knee becomes painful and engorged, 
Duval advises local friction, with the ointment of 
Iodide of lead, already alluded to ; and compres- 
sion by means of a flannel roller. The machine 
is then re-applied. Pain is always an indication 
for the removal of the apparatus and examination 



148 KNEE-JOINT. 

of the limb, as in the treatment of club-foot. 
When the sections are recent, a slight movement 
of the limb is apt to occasion great suffering. It 
should, therefore, be well supported while the appa- 
ratus is changed. 

It is sometimes at the option of the patient, 
whether the limb shall be entirely reduced, or 
w T hether it shall remain flexed at a slight angle ; 
the latter position being undoubtedly the most con- 
venient, especially in ascending a hill, or going up 
stairs. 

Different machines will be found described in 
the plates, (figs. 26, 28, 29, 30.) 

RESTORATION OF MOBILITY. 

At this stage, Little commences a new treatment 
for the purpose of restoring the mobility of the joint. 
The method consists of passive movements, frictions, 
vapor baths, &c. ; with the occasional flexion and 
extension by means of a machine applied to the 
leg. This difficult process requires a period vary- 
ing from three to six, and even twelve months. 



MECHANICAL TREATMENT WITH TENOTOMY DURING IN- 
FLAMMATION. 



Certain cases of anchylosis must be considered as 
a favorable termination of the disease. To inter- 
fere with the process, would renew the inflamma- 
tion. Little considers tenotomy inapplicable, until 



MECHANICAL TREATMENT. 149 

two or three years after the termination of active 
inflammatory symptoms ; and cites a case in which 
disease was renewed, apparently from a neglect of 
this rule. 

M. Duval maintains an opposite theory, and 
while he deprecates, in such cases, unaided mechan- 
ical treatment, he maintains, in a memoir addressed 
to the Academy of Sciences, in December, 1841, 
that " club-feet and false angular anchyloses of the 
knee, may be cured during the course of the inflam- 
matory maladies which produced them." 

The following passage more fully illustrates this 
point. 1 " When there is an inflammation of the 
knee, the seat of which is shown by the nature 
of the pain to be in the soft parts ; 2 which is 
not diffused, but circumscribed ; localized, so to 
speak, in the interior region of the articulation ; 
when the flexion is due to the permanent retrac- 
tion of the muscles ; when, I say, there is this 
combination of circumstances, and the inflammation 
has resisted all common therapeutic means, I be- 
lieve that everything is to be expected from the 
section of the retracted muscles, whatever be the 
local disorders of the articular parts. By this op- 
eration, we shall avoid also, the chance of anchylosis 
in a bad position. 

" Supported by numerous facts, I believe I may 
announce the following doctrine. Pain, inflam- 

1 Duval, p. 438. 

2 It may be remarked that little indication of the seat of the lesion 
can be drawn from the character of the pain. 



150 KNEE-JOINT. 

mation, alteration of intra and extra-capsular parts, 
or of the teguments, phlegmonous swelling, oe- 
dema, numerous cicatrices, suppurating surfaces ; 
all these circumstances, which seem to be so many 
contra indications, ought not to arrest the operator ; 
but are, on the contrary, indications to induce him 
to act. All prejudices which might have previously 
arrested him ought to yield to facts." 

The tendons being divided, gradual extension is 
applied to the limb. 

This principle is based upon a number of facts ; 
and is supported upon the ground, that extension, 
while it brings in contact new and less diseased 
parts of the articulating surfaces, separates the 
posterior and ulcerated portions from each other, 
and by relaxing the muscles, diminishes the pres- 
sure of the patella upon the anterior surface of the 
femur. Extension applied before section of the 
retracted flexor muscles, would evidently counter- 
act these indications in bringing the inflamed sur- 
faces more forcibly in contact. 

M. Guersent, of the Hopital des Enfans, asserts 1 
that in white swelling of the knee it is almost 
always advantageous to practise tenotomy, the 
moment circumstances are tolerably favorable for 
its performance ; that is to say, when the tumor is 
not extremely painful ; when the inflammatory 
symptoms begin to diminish in intensity. 

M. Ribes, a French writer of some note, ex- 

1 Gazette des Hopitaux, Juillet, 4, 1844. 



MECHANICAL TREATMENT. 151 

presses himself as follows : 2 " Medical art is rich in 
therapeutic remedies for the relief of white swell- 
ing of the knee-joint, but in almost all cases, from 
a simple cause, they have proved utterly inefficient. 
This cause is the permanent and forced contraction 
of the flexor muscles of the leg. Eh bien ! Why 
should we not perform, at the proper time, the sub- 
cutaneous section of the tendons of the semi-mem- 
branosus, semi-tendinosus and biceps muscles which 
keep up this uneasy state of things ? By this easy 
operation we may rationally hope not only to relieve 
the existing pain and distress, but also very mate- 
rially to promote the formation of anchylosis, and 
consequently the cure of the disease. This simple 
and safe operation is already admitted and recog- 
nised by surgeons. 5 ' 

It is unnecessary to say that great caution is to 
be exercised in accepting evidence of this sort, and 
especially in experimenting upon a lesion suffi- 
ciently grave to hazard the life of the patient. 

2 Med. Chir. Rev. Oct. 1844, p. 469. 



RICKETTY KNEES 



This variety of distortion, commonly known as 
knock knees and how legs, accompanies in many 
cases a ricketty diathesis in young; subjects. It re- 
sults in part from the flexibility of the bones. In 
the former variety the joint also becomes distorted, 
either from the relaxation of the internal ligament 
or the arrest of developement, or shortening of the 
external lateral ligament. The tibia is then di- 
rected obliquely from above downwards and from 
within outwards, while the femur forms another 
side of a triangle of which the summit is the knee. 
The articulating surfaces of the knee joint become 
oblique in the line of a perpendicular let fall from 
the summit upon the base of this triangle, and the 
extremities of the bone are often enlarged. 

Medical Treatment. — In infants, a tonic treat- 
ment often suffices to rectify completely the devia- 
tion, especially the outward curvature. The fol- 



TREATMENT. 153 

lowing formula will give an idea of the treatment 
of Guerin, in the case of a child of two or three 
years of age. 

1 1. Three salt water baths a week with the ad- 
dition of one pound of gelatine to each. 2. Fric- 
tion and massage* morning and evening. 3. Every 
other morning, fasting, a table-spoonful of syrup of 
gentian alternating with cinchona. 4. For ha- 
bitual drink, infusion of chicory (slight laxative 
and bitter) with one third Eau de Vichy and one 
third old Bourdeaux. 5. Light but substantial diet ; 
fresh eggs, simple soup ; cooked leguminous vege- 
tables and fruit ; but neither raw fruit nor milk. 
6. Country air. 7. No walking for some months. 

The above course of treatment was prescribed by 
M. Guerin for an infant of two and a half years of 
age, whose limbs, previously affected with the out- 
ward curvature, became straight at the expiration 
of a few months after its adoption. A simple 
change of air and diet often produces the same 
effect. 

Surgical Treatment. — When the child has at- 
tained the age of six or eight years, the firmness of 
the external lateral ligament in the imvard devia- 
tion, renders it expedient to divide it, rather than 
to attempt its extension. In certain aggravated 

1 Writer's MS. of Guerin's lectures. 

2 The term massage may be rendered in English by the word Sham- 
pooing. It consists of friction combined with pinching and kneading 
of the muscles, and with the gentle alternate forced extension and re- 
laxation of their fibres. 

20 



154 RICKETTY KNEES. 

cases, the tendon of the biceps is retracted, which is 
then to be divided. 

M. Guerin does not hesitate to divide the external 
lateral ligament, thus opening the articulation. He 
asserts that no ill effect results from this operation, 
(which I have often seen performed by him,) pro- 
vided the rules for subcutaneous perforations of the 
articulations are strictly adhered to. 

1. The section should be made in the position of 
extension. M. Guerin has endeavored to show 
that, in certain positions of the joints, a sort of 
vacuum is established in the articular capsules ; 
which aids the effusion of the synovial fluid from 
the secreting surface, by a sort of action of suction. 
If this be established it becomes a matter of impor- 
tance not to divide the capsule, when the joint is in 
such a position as to tend to draw into its cavity 
atmospheric and other surrounding fluids. 

2. The air should be carefully excluded. 

3. Perfect subsequent rest of the limb should be 
enjoined. 

With the subsequent and long continued use of 
an apparatus, as M. Guerin affirms, the internal 
portions of the oblique articulating surfaces become 
absorbed, the leg occupies a perpendicular, and the 
deformity is permanently relieved. 

Protracted mechanical treatment is required, to 
produce the requisite modification in the joint. Bon- 
net states, that he has never been able to obtain 
from this method a satisfactory result. 1 
I Op. cit., p. 575. 



PERMANENT FLEXION OF THE 
HIP-JOINT. 



The principles of treatment of false anchylosis of 
the knee, by gradual extension, apply equally to per- 
manent flexion of the hip. It is, however, more 
difficult to appreciate in this lesion the amount of 
change in the articular structures. The distortion 
is corrected by mechanical force, either alone or 
combined with the section of tendons. 

A year or two after the cessation of active inflam- 
matory symptoms, gradual reduction may be at- 
tempted, by the traction of a weight, spring, or other 
mechanical power. If the tendons resist the effort, 
the tenotome should be employed. 

The tendons which have been divided for this af- 
fection, are those of the adductor longus and magnus, 
rectus femoris, sartorius, pectineus, and, lastly, the 
tendon of the psoas and iliacus. The two last 
muscles have been divided by M. Guerin and by 
Dr. Sargent of Worcester. In the operation of the 



156 HIP- JOINT. 

latter surgeon upon a boy of ten years of age, in 
whom the deformity, of three years standing, was 
the sequence of apparent cerebral affection, the 
tenotome was introduced, about three inches below 
the anterior superior spinous process of the ilium, 
and carried in a direction parallel to Poupart's liga- 
ment, up to the edge of the femoral artery. The ten- 
don being extended, the knife was carried to the 
bone, when the tension yielded. 

Profuse hemorrhage followed the withdrawal of 
the knife, only arrested by compression sufficient to 
produce an eschar two inches in length. But the 
patient, who before the operation was a cripple, 
confined to his bed or walking upon his hands and 
knees, recovered, in a great measure, the use of his 
limb, and now walks erect without a cane. 

Jt should be mentioned, that the puncture was 
first made, at a point about one inch and a half be- 
low the spinous process of the ilium ; and above the 
position of the profunda and recurrent arteries, 
which would have then escaped division. It proved 
however, that the cicatrices of previous sections, 
had condensed the tissues to a degree which ren- 
dered them impervious to the tenotome, which was 
then introduced still lower down. The crural nerve 
was divided. The proximity of the tendon of the 
psoas to the large vessels, will hinder less dexterous 
surgeons from attempting its division, notwithstand- 
ing the eminently satisfactory results of this case. 1 

1 N. E. Quarterly Jour, of Med. and Surg. July, 1842. 



ANCHYLOSIS 



Little need be said upon this point. It is rare 
that a case of simple deformity justifies the surgeon 
in hazarding the life of the patient to a degree, 
which the operation proposed for anchylosis de- 
mands. The integuments and soft parts are widely 
incised, and the bone, after being exposed, is sawed 
apart. The patient is left in the conditions of a 
severe compound fracture. 

Dr. J. Rhea Barton first performed this operation 
upon the hip in 1827. 1 The neck of the femur was 
divided, and a serviceable joint was reestablished ; 
which, however, became again anchylosed at the 
end of six years. 

A similar operation w r as performed by Dr. Barton, 
upon a knee anchylosed at an angle, in May, 1835. 2 
The integuments were divided, and a wedge-shaped 

1 North Am. Med. and Surg. Jour., April, 1827. 

2 Am. Jour. Med. Sciences, Feb. 1838. 



158 ANCHYLOSIS. 

mass of bone was removed from the femur just 
above the condyles, the base of which, corresponded 
with the anterior surface of the bone. The limb 
was gradually straightened, the bone united, and 
the patient was enabled to walk without a cane. 

The first of these operations was to establish a 
joint, the second to correct the deformity of the 
limb." 

The latter operation was repeated with success 
by Professor Gibson in 1341, 1 and the former by 
Dr. Rodgers 2 in 1843, with like result. 

DiefFenbach proposes, in his last work, to break 
down the osseous union of the knee-joint with an 
instrument, and Malgaigne suggests the employ- 
ment of a chisel and mallet for the same purpose. 

1 Am. Jour. Med. Sciences, July, 1842. 

2 Ibid., Feb. 1843. 



LATERAL CURVATURE OF 
THE SPINE. 



The treatment of lateral, spinal curvature, has re- 
ceived much attention in France, and has recently 
been discussed at length, and not without warmth, 
in the Academy of Medicine. The principal advo- 
cates of the opposite modes of treatment, are MM. 
Guerin and Bouvier x ; the one insisting upon the 

1 The following are the conclusions of M. Bouvier : 

1. That the section of the sacro-lumbalis, longissimus dorsi, spi- 
no-transverse muscles, &c, is not immediately followed by diminution 
of spinal curvature. 

2. The changes which the curves undergo during the succeeding 
mechanical treatment, are exactly identical with the changes produced 
by this treatment alone, when it has not been preceded by the section 
of the muscles. 

3. The time necessary to obtain these changes is the same, whether 
we have recourse to orthopedic means alone, or practice also section 
of the muscles. 

4. In a word, dorso-lumbar tenotomy has no kind of influence in 
remedying lateral deviation of the spine, properly so called. 

M. Bouvier further concludes : 1. That the majority of lateral cur- 



160 CURVATURE OF THE SPINE. 

necessity of muscular section in certain cases of 
this distortion ; the other maintaining, that no ad- 
vantage is to be derived from it. 

The question relates to the duration and effi- 
ciency of the mechanical treatment, alone, or ac- 
companied with section of the muscles, and can 
only be satisfactorily determined by the analysis 
and comparison of a considerable number of cases, 
subjected to each method. The operation being 
attended with little pain, or chance of subsequent 
accident, is hardly to be taken into the estimate, if 
any advantage is to accrue from it. I believe M. 
Guerin has shown, as far as he is able, that the 
treatment is abbreviated in certain cases, by the 
division of the muscles* If it is established, that 
these tissues are liable to undergo the fibrous 
change in the region of the spine as w T ell as the 
extremities, as it undoubtedly is, they must offer a 
certain amount of resistance to any attempt to ex- 
tend them. That this resistance is not insur- 
mountable, that the spinal column can be extended 
in spite of its influence, will be readily conceded 
by those who have seen the tense and undivided 
muscles of the ham slowly yielding to the gradual 
application of mechanical force ; but this treatment 
is often accelerated by the section of the tendons 



vatures of the spine are not owing to muscular contraction. 2. That 
the etiology of the distortion, pathological anatomy, and clinical ex- 
periments proscribe the section of muscles of the back in the treat- 
ment of these curvatures. 



VARIETIES OF THE LESION. 161 

in the popliteal regions, and many are ready to ad- 
mit, that the same advantage is to be obtained by 
the division of the tense dorsal muscles upon the 
concave side of an exaggerated spinal curvature. 

The two modes of treatment need farther investi- 
gation ; but in rejecting the exclusive views of 
the partisans of either method, the evidence ren- 
ders it highly probable, that the treatment of lat- 
eral curvature is often accelerated by dorsal my- 
otomy. 1 



1 This subject has been revived in the Academie de Medicine by M. 
Malgaigne. After a tedious and excited discussion upon the value 
of dorsal myotomy, the matter was referred to a committee, of which 
Roux and Velpeau were members. The report of this committee 
was read to the Academy, 12th November, 1844 ; and may be con- 
sidered as embodying all that is yet settled upon this point. The fol- 
lowing are extracts from this report : 

" Although it should be proved that tenotomy was unavailing in 
the cases cited by M. Malgaigne, we should have no right to deny, for 
that reason, that the operation was ever efficacious." 

* # * a \y"e do not admit, that spinal curvatures are unaccom- 
panied with muscular contraction in all subjects." 

* * * " But it is important not to deceive ourselves upon the 
value of tenotomy in such cases, and not to decide upon it unless we 
can establish materially the existence of unyielding or tense cords 
upon the concave side of the deviation ; not during the influence of 
certain active positions, but when we try to straighten the curve by 
foreign force." 

And among the conclusions, 

" 6. Nothing at present justifies the opinion of those who attribute 
the majority of lateral curvatures of the spine to convulsive or active 
retraction of the muscular system. 

" 7. But, the secondary shortening of certain muscles in the con- 
cavity of the curves, ought to hinder us from rejecting, a priori, and 
absolutely, spinal myotomy." 

The question thus stands much as it did before. 
21 



162 CURVATURE OF THE SPINE. 

The pathology of the lesion has been thoroughly 
reviewed by M. Guerin, whose opportunities have 
enabled him also to investigate manv practical con- 
siderations connected with the treatment. 

The following is a brief exposition of the views of 
If. Guerin, with such additions as embrace the 
more important suggestions of other writers. 

CAUSES. 

A lateral deviation of the spine presents certain 
alterations in the conformation, structure and rela- 
tive position of the vertebral column and surround- 
ing tissues. The advanced age of the patient, the 
long duration, or the exaggerated degree of this dis- 
tortion, are conditions which give rise to secondary 
alterations, and place such deviations beyond the 
reach of art. 

Tuberculous and other disease of the bones, 
anchylosis and osseous transformation of the fibrous 
structures, are also cases foreign to the class about 
to be described. 

Certain forms are eminently adapted to receive 
aid from an operation ; greater in proportion to the 
youth of the patient and the inconsiderable degree 
of distortion. In such cases, the muscles, which 
form the chord of the principal curvature, are either 
primitively or consecutivelv contracted ; and dis- 
play themselves in certain positions of the body in 
the form of a resisting fasciculus, which hinders 
the vertebral column from assuming a normal posi- 



CAUSE OF THE CONGENITAL VARIETIES. 163 

tion. This muscular retraction is identical with 
that of club-foot and wry-neck. 

As a primitive lesion, and a cause of osseous dis- 
tortion, lateral deviation is congenital or non-con- 
genital. 

CAUSE OF THE CONGENITAL VARIETY. 

That the congenital variety is due, like other 
congenital deformity, to muscular spasm, resulting 
from nervous influence, is shown 

1. By the frequency with which deviations of 
the spine and other articular deformities, such as 
exaggerated distortion of the superior and in- 
ferior limbs at their different joints, and also of 
the hands, feet, &c. coexist in fcetal monstrosi- 
ties, which offer evident alteration of the brain and 
spinal marrow. These cases present marked mus- 
cular traction in the direction of each deformity, 
proportioned in degree to the intensity of the le- 
sions of the nervous centres. 

2. By congenital deviations of the vertebral col- 
umn observed in the living subject, and accompa- 
nied either with strabismus, club-foot, torticollis, or 
other distortion of the skeleton, or with appear- 
ances of convulsions in the face, irregularity of the 
two halves of the cranium, or diminution of force 
and even paralysis in certain parts of the muscular 
system ; or, finally, with veritable congenital spas- 
modic affections, such as epilepsy, hemiplegia, par- 
aplegia, with or without muscular contraction. 



164 CURVATURE OF THE SPINE. 

In the non-congenital form, it is equally shown 
by cases of spinal deviation, dating from a period 
subsequent to birth and immediately following cer- 
ebral or cerebro-spinal affections. 

It is accompanied as in the two preceding forms, 
with a great number of other deformities, such as 
strabismus, torticollis, club-foot, deviations of the 
knee, all dating from muscular convulsions, and ac- 
companied with retraction of the muscles exactly 
in relation with the form and degree of the deform- 
ities. 

In these three varieties, the essential characters 
of the disease are the same, and identical with those 
in which the deviation alone remains to indicate 
the existence of a similar cause at some previous 
period. 

MUSCULAR RETRACTION. 

Muscles* The anatomical characters of the re- 
tracted tissues accompanying spinal deviation are 
the same as those of retracted muscles in other 
regions. 

At first, in a state of spasmodic contraction, they 
become in a measure paralyzed, their developement 
is arrested, and degeneration commences ; fibrous 
if they are submitted to traction ; fatty in a state 
of repose. 

The condition of active contraction differs from 
that of passive retraction. In the former, the mus- 
cle is tense, acts as the immediate cause of the ver- 



MUSCULAR RETRACTION. 165 

tebral curve and limits its extent. In the latter 
condition, it merely accommodates itself to the dis- 
tance between the extremities of the curve, and is 
less forcibly extended. 

In both cases the shortened tissue is moderately 
resisting. In the former or fibrous change, the 
tissues are felt beneath the skin, a hard, fascicu- 
lated mass, occasionally giving the sensation of 
fibro-cartilage, if the column be extended. The 
muscle is found to be diminished in size, retracted, 
paler, of a whitish yellow, of an eminently fibrous 
or fibro-fatty texture, contrasting strongly with the 
regular form, red color, and fleshy consistence of 
the corresponding normal muscles. The longis- 
simus dorsi is occasionally so fibrous that its apon- 
eurotic and tendinous portion acquires a double 
length at the expense of the muscular portion. 

In the fatty degeneration, the muscle becomes 
somewhat softer than natural, and retains its orig- 
inal volume. 

After the section of muscles thus retracted, the 
extremities reunite by means of an intervening por- 
tion, of adequate length ; this tissue regains its 
normal character, and becomes, in a word, muscle. 

Vertebrce. Upon the convexity of the curvature, 
both the vertebrae and their intervening flbro-carti- 
lages increase in thickness, while the concavity 
is marked by a corresponding absorption and di- 
minution of substance of the same parts. They 
thus acquire, individually, a wedge shape. 

Ligaments, In cases of long standing or of 



166 CURVATURE OF THE SPINE. 

great deviation, the ligaments may become re- 
tracted and even ossified, in consequence of which 
the vertebrae tend to become anchylosed. 

Thorax. The ribs follow the deviation of the 
spine, and in exaggerated examples the thoracic 
cavity is distorted and compressed, and the con- 
tained viscera are modified in position, form and 
structure. Portions of the lungs may become in- 
durated, and even acquire a fibro-cellular struc- 
ture. 1 

The progress of this sort of deviation is chiefly 
due to mechanical causes. The column once bent 
is powerfully acted upon by the weight of the 
body in a vertical position, to a degree which 
slackens the extended cords, and renders it difficult 
to detect them beneath the skin. They are not 
for this reason less efficient in retaining the spine 
in its anormal position ; and an upright posture 
commonly restores their tenseness and indicates 
their locality. In a young and recent subject this 
tenseness may be made apparent by suspending 
the body by the head. 

The amount of retraction is sometimes consider- 
able, amounting to a third of the length of the mus- 
cle, and is always proportioned to the curvature. 
In some cases the muscles, situated on the convex 
side of a curvature, slip over the spinous processes 
to occupy a position upon its concavity. 

iDiff. du Syst. Oss., p. 26. 



NON-CONGENITAL VARIETIES. 167 



CAUSES OF NON-CONGENITAL VARIETY. 

Among the causes of the non-congenital form of 
spinal deviation, are 

1. The convulsions of infancy. 2. Local or 
general spasmodic action occurring at a later period 
of life. 

These causes, recognised as producing distortion 
of the limbs and neck, have also their influence 
upon the muscles of the vertebral column, which is 
thus suddenly curved, though the resistance of its 
surrounding tissues may render the deviation so 
inconsiderable, as to prevent its immediate de- 
tection. Wounds of the muscles of the back, 
and blows or other violence to these tissues, may 
be an immediate cause of their permanent con- 
traction. 

Other causes are, a want of general muscular 
and ligamentous force ; an inequality in the antag- 
onizing power of opposing muscles ; the paralysis 
of some of them ; an abnormal inclination of the 
plane of support ; a primitive inequality of the two 
halves of the skeleton ; ricketty or scrofulous ten- 
dencies ; any of which suffice either to create a 
deviation, or to occasion a pre-disposition to curva- 
ture, which the agency of slight causes developes. 
The superincumbent weight of the body, and the 
tendency of the muscles to accommodate their 
length to the distance between the approaching 
extremities of the arc, augment the curve in pro- 



168 CURVATURE OF THE SPINE. 

portion to their force, and the inability of the parts 
to resist their influence. 



CURVATURE AND TORSION. 

A lateral deviation of the spine consists of two 
elements, to be separately considered. 1. Curva- 
ture.- 2. Torsion. 

Curvature is of two kinds. The one occupies 
the immediate seat of the lesion ; the other is an 
accompanying and compensating deviation. The 
trunk always tends to maintain an upright position. 
As soon as a part of the vertebral column deviates 
from a perpendicular, another portion institutes a 
curve in an opposite direction, by way of restoring 
to the mass its centre of gravity. For this reason, 
a single curve never exists alone. It is rare that 
two are found unaccompanied by a third. Three 
are very common, and four occasionally met with. 

The position of the spinous processes is not in 
all cases an indication of the extent or direction of 
the deviation. In a pathological specimen exhib- 
ited to the Academy of Medicine, the column 
viewed from behind, offered a single curve, while 
the bodies of the vertebrae in front, presented four. 
This apparent anomaly is due to torsion, which ac- 
companies all cases of deviation. 

The principle of torsion is illustrated by an at- 
tempt to bend a blade of grass, or a flat, flexible 
stick, in the direction of its width. The centre 
immediately rotates upon its longitudinal axis to 



CURVATURE AND TORSION. 169 

bend flatwise in the direction of its thickness. In 
the same way the spine, laterally flexed, turns upon 
its vertical axis to yield in its shortest or antero- 
posterior diameter. 

The centre of rotation or torsion is a vertical 
line through the summits of the spinous processes, 
which remain, in consequence, comparatively sta- 
tionary, while the bodies of the vertebrae rotating 
around this centre, tend to occupy the outside of 
the convexity. For this reason it often happens 
that the principal curve alone can be detected by 
the direction of its spinous processes, and writers 
have been thus led to admit the existence of single 
curvature. 

Each vertebra of a curve is laterally bent upon 
its antero-posterior axis ; and the spinous processes 
are thus inclined towards the transverse, upon the 
convexity of the deviation. The vertebrae of transi- 
tion from one curve to another are alone to be ex- 
cepted from this rule. 

Other elements of the mechanism of torsion, are, 

1. The disposition of the articulating surfaces; 
which, in the cervical and dorsal regions, are 
oblique, while in the lumbar region they are nearly 
transverse. 

2. The resistance of the lateral muscles, which 
become subsequently retracted. Among the prin- 
cipal, are the costal insertions of the longissimus 
dorsi, the inter-spinales, and the inter-transversales 
muscles and ligaments, which confine the summits 



170 CURVATURE OF THE SPINE. 

of the processes, while the bodies of the vertebrae 
yield to the effort of flexion. 

GIBBOSITY. 

To the action of torsion is due the prominence 
of the ribs, muscles, scapula and shoulder upon the 
convex side of the curve and the corresponding de- 
pression upon the concavity. This deformity, com- 
monly termed gibbosity, is constant in cases of pa- 
thological deviation. 

CURVES — THEIR POSITION AND MECHANISM. 

It is rare to find two vertebral columns, pathologi- 
cally distorted, which offer precisely the same charac- 
ters. Nevertheless certain curves are more frequent 
than others. A convexity to the right, above, and to 
the left, below, is more common than the reverse. 

The principal curve, commonly occupies the dor- 
sal, or dorso-lumbar region ; a circumstance ex- 
plained by the fact, that the centre of the move- 
ments of totality, of the vertebral column, and of 
lateral flexion in particular, is situated at the point 
of junction of the dorsal and lumbar regions. It is 
due to the following anatomical disposition of the 
articulation, uniting the eleventh and twelfth dorsal 
vertebras. 

1. "The articulating facettes are more perpen- 
dicular and transverse. 

2. "A sort of notch is formed by a prolongation 



CURVES. 171 

upwards and forwards of the superior tubercle of 
the transverse process of the twelfth dorsal vertebra, 
which is recurved like a hook, so as to convert into 
a transverse groove, the space comprised between 
this appendix and the superior articulating process 
of the same vertebra. In this groove is received 
the inferior edge of the articulating facette of the 
eleventh dorsal vertebrae, which slides there without 
the least of obstacle during the movements of lat- 
eral flexion of the column. Besides this circum- 
stance, certain muscles, the quadrati-lumborum, the 
common mass of the sacro-lumbalis, longissimus 
dorsi and semi-spinales, which are the agents of 
lateral flexion, are, to a certain extent, circum- 
scribed in this region, and belong especially to it." 

A similar conformation, but less marked, exists 
in the neighboring dorsal vertebrae, which gradually 
lose this peculiarity in receding from this point ; 
so that the natural curve, in the lateral movements 
of the spine, decreases from the loins upward. 

A single principal deviation once established, 
curves of compensation immediately follow, as the 
result of subsequent active muscular contraction, 
and the trunk is restored to a perpendicular. 

These secondary curves are sometimes hardly ap- 
preciable. That occupying the cervical region is 
often slight, and when masked by the action of 
torsion, is sometimes not indicated by a correspond- 
ing curve of the spinous processes. As was before 
remarked, an evident alternate deviation of the 
bodies of the vertebrae of the entire column, some- 



172 CURVATURE OF THE SPINE. 

times presents no appreciable variation from a per- 
pendicular, when viewed from behind. 

A dorso-lumbar deviation is always arrested in 
the dorsal region to give place to a curve of com- 
pensation. Though more frequent at the junction 
of the lumbar and dorsal vertebrae, the distortion 
may occupy any portion of the vertebral column, 
and is attended with a general prominence of the 
parts upon its convexity, and a corresponding de- 
pression in its concavity. 

Exaggerated deviation is accompanied by ivrin- 
kles of the skin, corresponding to the concave side 
of the most considerable curve ; often a short dis- 
tance below the axilla. 

The trunk, supported by alternate curves, is very 
slightly, or not at all, inclined ; the hip, never ele- 
vated, if the legs be of equal length ; and the sub- 
ject does not necessarily walk lame. 

The muscles, which are commonly retracted in 
the principal or dorso-lumbar curvature, are the 
common mass of the sacro-lumbalis and longissi- 
mus dorsi ; in the central dorsal region, the same 
mass, with the spinalis and semi-spinalis dorsi ; at 
the cervico-dorsal curve, the complexus, cervicalis 
ascendens and transversalis colli. 

The lesion may occupy other positions. Certain 
portions of the trapezius may be retracted and 
fibrous, by the side of other portions, paralyzed, 
atrophied and membranous, and by the side of 
other healthy muscle. All the muscles of the back 
are sometimes retracted, producing great distor- 



TREATMENT. 173 

tion. The long dorsal may be alone retracted, by 
the side of the sacro-lumbalis, passively affected ; 
or a simple fasciculus of one of these muscles, may 
offer a state of tension in the midst of healthy tis- 
sues. In such cases it is amply proved, that the 
extended muscular bands, when subjected to tor- 
sion, may become retracted ; in other words, their 
developement is arrested ; they are, in a measure, 
paralyzed, and more or less transformed into 
fibrous tissue. In such conditions they fulfil, with 
regard to the spine, the functions of a string in a 
bent bow. 

TREATMENT. 

Distortion of the spine is less amenable to treat- 
ment than other deformity ; chiefly, perhaps, from 
the difficulty of applying to it a permanent and 
properly directed mechanical force. A first diffi- 
culty presents itself in the necessity of flexing the 
entire body, in order to affect corresponding flexion 
of the vertebrae. The mass is unwieldy, and a 
lateral effort can be applied only through the inter- 
vention of the ribs, shoulders, or pelvis. Nor can 
this power be maintained for a length of time. 
The respiration is impeded, the posture is constrain- 
ed, the integuments are irritable, and the trunk 
impatient of confinement. The mechanical treat- 
ment must be frequently suspended, and in these 
intervals, various influences, among which the ver- 
tical weight of the trunk is not the least, tend to 



174 CURVATURE OF THE SPINE. 

reproduce the deformity. The subsequent exer- 
cise of the muscles, so important in orthopedic 
treatment, can only be accomplished in the region 
of the spine, by exaggerated and comparatively fa- 
tiguing movements of the whole trunk. 

It is obvious, that such conditions are far less 
promising than those which commonly attend the 
treatment of club-foot ; where the whole distortion 
is embraced by the apparatus, which maintains an 
unremitting and progressive force, as long as it 
may be required, and where the gentle exercise of 
walking subsequently secures the advantage ob- 
tained from the use of a machine. 

The results of the treatment of spinal curva- 
tures are, as might be expected, much less satis- 
factory than those of most other distortions, while 
the time required is longer ; and hence the dif- 
ficulty of deciding between the claims of different 
methods. 

The deformity is often inconsiderable and sta- 
tionary, and requires no treatment. 

At other times the constitution of the patient is to 
be fortified with change of air, and food, with salt 
baths, cold douche, frictions and massage. Exercise 
in the open air is important, and the mechanical treat- 
ment of this deformity is always combined with gym- 
nastic exercises. These should be so contrived as to 
strengthen the muscles upon the convexity of the 
principal curve, and to elongate those upon its con- 
cavity. Such are, climbing the under-side of a spiral 
ladder; turning a crank above the head and on 



SURGICAL TREATMENT. 175 

the side of the concavity, in the horizontal posi- 
tion ; a lateral rocking horse inclined towards the 
side of the concavity ; which will serve as exam- 
ples of a great variety of contrivances, obvious to a 
machinist. 

A bag of sand or shot, carried upon the head, 
while the patient walks, is an excellent method of 
exercising the dorsal muscles. 1 But when the pa- 
tient is at rest, its vertical weight would obviously 
tend to exaggerate the curvatures. 

If, however, in certain postures of the patient, a 
tense fasciculus appears beneath the skin, upon the 
concave side of the principal curvature in the posi- 
tion of a chord, uniting the two extremities of the 
arc, there is little doubt that the progress of me- 
chanical treatment will be accelerated by its subcu- 
taneous division. Were the section of muscles un- 
necessary, the operation is attended with no dan- 
ger and with little pain or hemorrhage. It offers 
no impediment to subsequent mechanical treatment, 
which is the same in every respect except in its 
duration, whether the muscles be severed or not. 

SURGICAL TREATMENT. 

In such a case, the exact position of the re- 
tracted fasciculus is ascertained by placing the pa- 
tient in a vertical or horizontal position ; or by 



1 The straight backs of negroes, and people accustomed to carry 
weights upon their head, are proverbial. 



176 CURVATURE OF THE SPINE. 

making extension, if requisite. Parallel extension 
is sometimes used to effect an elongation of the 
muscles preparatory to their section. 

OPERATION. 

M. Guerin nowhere indicates the manual of the 
operation. In those I have seen performed by 
him, amounting to a dozen or more, the patient 
was laid upon his belly upon the table. The 
hands being extended by the side, the patient was 
desired to raise his head ; an action by which the 
dorsal muscles were brought into play and their re- 
tracted fibres made tense. A fold of skin was then 
pinched up at the outer edge of the extended fas- 
ciculus, and, a puncture being made, the myotome 
was introduced flatwise at its base, at a point 
which afterward receded to the distance of an inch 
from the external border of the muscle. The knife 
being then turned upon the mass, the fibres were 
divided by a sawing motion communicated to the 
convex edge of the blade. 

By reason of its fibrous character, the resisting 
cord is divided with precision and at once ; and its 
complete section is attended with a sharp and dis- 
tinct explosion, as the extremities recede one from 
another. On the other hand, non-retracted mus- 
cular fibres are soft, and yield to the instrument, 
which is unable to effect either a clear or a rapid 
division of their substance. 

Immediately after the operation, certain elements 



MECHANICAL TREATMENT. 177 

of the deformity disappear at once ; and what is 
important, other fibres rise to take the place of 
those which have been severed. They often oc- 
cupy nearly the same position, and their section is 
attended with an additional correction of the devi- 
ation. 

The same phenomenon sometimes appears at the 
end of six or eight months after the commencement 
of mechanical treatment. When in such a case 
the curvature remains undiminished during several 
months, the re-division of the muscles is attended 
with a new diminution of the curve, generally 
rapid during the first days after the operation. 

MECHANICAL TREATMENT. 

Mechanical treatment is effected either by por- 
table apparatus, which allows the patient to move 
about, or by mechanical beds, in which force is ap- 
plied horizontally. 

In the former, a broad metallic belt embraces the 
hips, and serves as a fixed point, from which exten- 
sion is applied either to the head or more com- 
monly to the shoulders. The inconvenience of the 
latter method is apparent. The shoulders and 
scapula yield to the force, while the vertebral col- 
umn is unaffected by it. 

The apparatus ofHossard, modified by Tavernier, 
does not aim at extension. It consists of a belt of 
wadded leather, four or five inches broad, and fixed 
around the pelvis by horizontal and perineal straps. 



178 CURVATURE OF THE SP1JNE. 

Behind, a steel upright reaches to the height of the 
shoulders, and is attached to the belt by ratchet 
work, which admits of its lateral inclination tow- 
ards the shoulder of the concave side of the 
curve. From its summit a broad strap winds spi- 
rally downward round the convexity of the curve, 
which it presses towards a perpendicular, and is 
fixed to the belt in front. The trunk being thus 
thrust from its centre of gravity, tends, in recover- 
ing itself, to correct the spinal deviation. 

The strap should traverse the most salient point 
of the ribs behind, while a second strap passes, if 
required, in the contrary direction around the lumbar 
curve. This efficient apparatus does not forbid active 
exercise. Its great advantage is, that the correct- 
ing force is purely muscular ; and derived from the 
efforts of the body to regain the perpendicular from 
which it is thrust by the machine. 

On the contrary, the shoulder supports ; and the 
Minerva already described, 1 which exercises traction 
upon the head, are substitutes for muscular action, 
which they enfeeble, in supplying its place. 

2 Marshall Hall proposes to take a plaster cast of 
the body, in an upright position, and to deposit 
upon it, by the galvanoplastic method, a coating of 
copper. The whole is sawed in two, vertically, 
and a pair of copper corsets are thus produced ex- 
actly fitted to the trunk. The idea is ingenious, 

1 See page 124 and plate, fig. 24. 

2 Lancet, Feb. 3, 1844. 



PARALLEL EXTENSION. 179 

but the principle of support is open to the objection 
just mentioned. 

Various orthopedic beds have been devised for 
the purpose of effecting horizontal extension. In 
these the force is best applied in one of two ways. 

1. In a direction parallel to that of the spine. 

2. In a direction perpendicular to it. 

PARALLEL EXTENSION. 

Parallel extension is effected by fixing the pelvis 
and applying an extending power to a series of 
straps passed round the chin and head. This is 
best effected by the machine about to be described 
for the second method. 

This method is applicable in old and very pro- 
nounced curvatures, where the extent of the curve 
gives power or purchase to this simple traction. 
Also in the deviations with four curves, or where 
two closely follow each other in the dorsal region. 
It is then impossible to apply perpendicular force to 
each curve separately, on account of their proximi- 
ty. Continued force of this sort is liable to pro- 
duce a relaxation of the ligaments, which predis- 
poses the spine to a recurrence of the deformity. 
It also tends to efface the natural antero-posterior 
curves. Many young people treated in establish- 
ments where these beds are exclusively employed, 
have their backs flattened ; the shoulders and other 
regions of the vertebral column being reduced to 
the same plane. These ill effects are to be com- 



180 CURVATURE OF THE SPINE. 

bated by suitable gymnastic exercises alternating 
with extension. Horizontal extension also acts 
but indirectly upon the wedge-shaped conformation 
of the vertebrae, its power diminishing as the curve 
becomes less marked. 

SIGMOID EXTENSION. 

The method which Guerin has called sigmoid 
extension consists of several elements. 

The first of these is parallel extension, the head 
and pelvis being respectively attached to the top 
and bottom of the bed. 

The second is a lateral force applied to a point 
upon the side of the trunk corresponding to the 
convexity of the curve, and in a direction perpen- 
dicular to it. The action is analogous to that of 
straightening a bow, when the extremities are 
held in the hands, and the knee is applied at an 
intermediate point of the convexity. It has several 
advantages over parallel extension. The power is 
applied to greater advantage ; and a temporary 
curve in the opposite direction is substituted for 
the original curve ; as in the attempt to straighten 
a bow. 

This feature of sigmoid extension is of great im- 
portance. To effect it, two uprights are placed 
upon opposite sides of the bed, one above the other, 
at points which correspond with the convexity of 
each curve ; and are capable of being advanced 
towards a median line and fixed in that position. 



PARALLEL EXTENSION. 181 

This simultaneous application of the power to the 
extremities and convexity of the double curve or S, 
suggested the term sigmoid extension. It is the 
more efficient, as many deviations have their prin- 
cipal curve at the level of the dorso-lumbar region, 
which answers to the articulation already described 
of the eleventh and twelfth dorsal vertebrae ; a dispo- 
sition which greatly aids the action of the machine. 

A third peculiarity is the combination of flexion 
and extension. It is effected by placing the cen- 
tres of rotation of the upper and lower portions of 
the bed upon opposite sides. In illustration of this, 
provide a strip of board, and a pair of compasses, 
the length of which is equal to the width of the 
board. Saw the board across, and placing the shut 
compasses horizontally in the interval of division, 
attach a leg to each of the sawed surfaces. The 
joint of the compasses forms a lateral centre of ro- 
tation for the boards ; and in flexing one board 
upon the other, the triangular interval of separa- 
tion gradually increases. If the board be again 
sawed and provided with a similar joint upon the 
opposite side, this arrangement will represent the 
orthopedic bed, employed by M. Guerin, in which 
a joint corresponds to each of the two principal 
curves. The body of the patient fixed upon it is 
at once flexed by the joints, and extended by the 
increasing intervals of separation. 

A helmet is united to the apparatus by a uni- 
versal joint, and serves for the mechanical treat- 
ment of torticollis. It is capable of being fixed in 



182 CURVATURE OF THE SPINE. 

any position which the cervical vertebrae in their 
normal state, are capable of assuming, and serves as 
a point of counter-extension to the pelvis, which is 
attached by a belt and straps to the foot of the 
bed. It should be remarked, that the extension of 
the head is in reality effected, not by the helmet, 
but by a stuffed collar of iron suspended from its 
lower margin. 

M. Guerin finds it inexpedient to flex simulta- 
neously, the upper and lower tables of the bed ; 
and when there are two principal curvatures of 
nearly the same degree, they are treated alternate- 
ly in different parts of the day. 

When there is a single principal curve for which 
the muscles have been divided, M. Guerin directs 
attention to this, to the exclusion of the less 
marked curves of compensation. In such a case, 
the body being extended, is thrust to the side of its 
concavity by the aid of the uprights alone ; one of 
which is applied to the convex point, while the op- 
posite supports the pelvis. The tables of the bed 
are then not flexed. 

In certain scrofulous and other deviations with- 
out muscular contraction, simple flexion may be 
required, without extension. It is effected by a 
bed like that described ; but possessing but one 
division, with its axis of lateral flexion at a point 
equi-distant from the two sides. 

The apparatus will be better understood by re- 
ferring to the annexed drawings, (figs. 31, 32, 
33, 34.) 



CONTRACTION OF THE HAND 
AND FINGERS. 



The section of tendons in the hand is much less 
uniformly productive of good results than in many 
other regions, and its propriety has been disputed. 
The indications for the operation are not yet clear- 
ly pointed out. It has been performed by most 
orthopedic surgeons, but it is doubtful if it is ever 
efficacious, while it is certain that the fingers are 
sometimes disabled by the operation. 

CAUSES. 

The distortion is sometimes due to diseases 
of the bone. That form which is the effect of 
contraction of the tendons, or which is accom- 
panied by this symptom, recognises a variety 
of exciting causes. It is occasionally, but rarely, 
congenital. It results from cutaneous eruptions, 
fractures, wounds or abscesses. It also follows 



184 CONTRACTION OF THE HAND AND FINGERS. 

paralysis of antagonizing muscles. In the variety 
thus accompanied by active or passive muscular re- 
traction, which alone oners conditions for tendinous 
section, the tendons are resisting and in high relief 
beneath the skin. 

The deviation is rarely due to a single set of 
muscles, and it commonly presents a combination 
of the various movements of the hand. Flexion of 
the hand is sometimes accompanied with extension 
of the fingers or with a lateral inclination, and with 
flexion of the phalanges. The muscles of the arm 
not unfrequently participate in the affection, and 
the fore arm is more or less flexed or pronated. 

It has been demonstrated by Froriep of Berlin, 
that the palmar aponeurosis, when retracted, may 
aid in the flexion of the phalanges, by means of 
fibres which it supplies to each side of the fingers. 
In certain cases the joints are partially anchylosed, 
and require forcible extension. 

The section of the flexor tendons of the fingers is 
frequently, if not in all cases, followed by a loss of 
power in the hand. The phalanges can no longer 
be flexed. It has therefore been a question whe- 
ther their division should ever be attempted. In 
support of the affirmative, it is urged that the de- 
formity is in a great measure relieved ; and that in 
unsuccessful cases the hand yet retains sufficient 
power to grasp large objects. But it is probable, 
that were the chances fairly represented, few pa- 
tients would consider the shape of a hand an in- 
ducement to hazard the loss of its use ; and the 



CONTRACTION OF THE HAND AND FINGERS. 1 85 

histories of cases like that of M. Doubouvitski, 1 will 
deter most surgeons from attempting the division 
of the tendons in this region. 

OPERATION. 

For the deviation of the entire hand, which is 
rare, it suffices to divide the palmaris longus and 
brevis, and perhaps the flexor carpi ulnaris if there 
be a lateral inclination of the hand. These ten- 
dons are subcutaneous, and easily divided. The 
motions are generally restored, when the contrac- 
tion is not due to paralytic affection of the antago- 
nizing muscles. 2 More commonly, the flexors of the 

1 In this well known case, many tendons of the forearm and hand 
were divided by M. Guerin ; among them, the deep flexor in the 
fingers and the superficial flexor tendons in the forearm. The pa- 
tient, who was before able to retain an object in the contracted 
fingers, lost all power of flexing the phalanges, and the hand became 
in consequence, comparatively useless. 

Similar instances are not wanting. The case of Jenny Wilson re- 
ported by M. Guerin to the Acad, des Sciences, to illustrate the inno- 
cuity of the division of thirteen tendons, was examined by M. Phillips, 
a year afterwards at the Salpetriere. He sums up the anatomical 
details as follows : " This patient remained during nine months in the 
service of M. Guerin at the ' Hopital des Enfants.' She bitterly de- 
plores, as well as her mother, the results of all the operations she 
has undergone. Before these sections she could make a move- 
ment with the fingers which permitted her to hold a needle, which 
she then seized with the mouth to be again taken by the fingers. By 
these movements she could sew fast enough to make shirts. Now, 
this sole resource no longer remains ; she is condemned to vegetate 
in a service of incurables at the 'hospice de la Salpetriere.' The 
thirteen sections were made in the forearm, in the two legs, and two 
feet." — Annates de Chirurgie. Paris, 1841; t. ii. p. 130. 

2 Little in Lancet. Dec. 16, 1843. 

24 



186 CONTRACTION OF THE HAND AND FINGERS. 

fingers are also retracted and the phalanges drawn 
toward the palm. The first phalanx often remains 
straight, while the two last are flexed upon it. 

After dividing the flexors in the forearm, the hand 
may be more or less extended, but when, as it often 
happens, the fingers are stiff and unyielding, the 
surgeon is called upon to decide upon the expedi- 
ency of additional sections in the palm and fingers. 
In such a case, extension may be sometimes effected 
by force, but it should be previously ascertained 
that the resistance is not due to the retraction of 
tendons or palmar aponeurosis. 

As was before stated, the division of the tendons 
of the palm and fingers is rarely successful. The 
section of the deep flexors at the level of the 
second phalanges allows the extension of the fingers 
but paralyzes their power of flexion. The tendon 
is drawn back through the bifurcation of the super- 
ficial flexor, and an interval is thus formed between 
the divided surfaces, which are hindered from unit- 
ing by the presence of the synovial fluid. 

In the present state of knowledge upon this sub- 
ject, it may be affirmed that the superficial flexors 
of the fingers should never be divided at the base 
of the first phalanx, but rather in the forearm. 
The proximity of the median nerve at the wrist, 
compels us to divide the deep-seated flexors in the 
palm, if at all ; but the reunion of their tendons is 
uncertain. The operation is indicated only when a 
single finger is permanently flexed, and interferes 
with the movements of the rest. 



CONTRACTION OF THE HAND AND FINGERS. 187 

The flexors of the toes are sometimes retracted, 



and may be divided in the sole, the reestablish- 
ment of motion being here of comparatively little 
importance. 

Little benefit is obtained in most cases from a 
simple division of the cicatrices consequent upon 
burns, especially upon the palmar surface. 

MECHANICAL TREATMENT. 

Immediately after the section, the patient is apt 
to experience severe and deep-seated dragging pain 
in the arms, due to the forcible contraction of the 
muscles. The pain is alleviated by frictions and 
steaming. 

The hand being well protected, is confined in 
contact with a straight splint, extending from the 
elbow to the extremities of the fingers. The splint 
may be provided at the wrist with a hinge regu- 
lated by a screw or other mechanism, so contrived 
as to fix it at any required angle. The whole may 
be supported in a sling. 



CONGENITAL DISLOCATIONS. 



Numerous well described cases of the different 
varieties of congenital luxation are to be found in 
the papers of various writers, especially since the 
subject has received general attention. Although 
interesting, in an anatomical and pathological point 
of view, they are generally to be referred to the 
principles laid down by Guerin in his memoir upon 
this subject, which is the groundwork of the fol- 
lowing chapter. 

CAUSES. 

Certain forms of congenital dislocation are due 
to the paralysis of certain muscles. 

Luxation resulting from disease of the bone is 
unaccompanied with active muscular retraction, and 
easily distinguished. 

The affection is due in a large majority of 



LOCALITY AND PROGRESS. 189 

cases to muscular retraction ; and resembles in 
this respect club-foot and wry-neck. It accom- 
panies these distortions, and is found in acepha- 
lous and other anormal conformation of the nervous 
system. 

LOCALITY AND PROGRESS. 

Any joint in the body is liable to dislocation from 
muscular retraction. 

The luxation may be partial or complete. At 
an early period of foetal life, the articulating cavi- 
ties are imperfectly formed, and the articular ex- 
tremities easily extend the yielding ligaments, and 
escape from their normal positions. At a later pe- 
riod, when the sockets are more completely devel- 
oped, the dislocation is commonly partial. 

The progress of the luxation is due to the arrest 
of the developement of certain muscles ; to the 
physiological contraction of others ; and to the su- 
perincumbent weight of the body. These forces in 
the end complete a dislocation which was at birth 
partial. In such cases, an indeterminate length of 
time is required to complete the luxations. The 
femur in such cases rarely escapes from the aceta- 
bulum in less than three or four years after birth ; 
and surgeons have been thus led to suppose the 
affection non-congenital. 

An essential step towards the reduction of the 
dislocation, is the division of the retracted muscles, 
whether actively or passively affected. 



190 CONGENITAL DISLOCATIONS. 



CONDITION OF THE MUSCLES AND SOFT PARTS. 

The muscles originally concerned in inducing 
the luxation are actively retracted. Others, pas- 
sively retracted, merely accommodate themselves 
to the approximated points of insertion. Their di- 
rection is often changed. 

Their texture is either fibrous, when tense ; fatty 
when exempt from traction ; or hypertrophied when 
tasked with the duties of inefficient muscles. 

Muscles primarily retracted, require division. 
Those passively shortened may be, in certain cases, 
mechanically extended, but sometimes require divis- 
ion. The fatty tissue opposes no obstacle to the 
normal position of the part. 

The arteries become flexuous and retain their 
length, but decrease considerably in volume. 

The veins increase in number and in size. 

The nerves are shortened, probably through the 
agency of their fibrous sheath ; and their mechanical 
extension, during treatment, is attended with pain. 

The cellular tissue increases in quantity, fills up 
depressions, and takes the place of the atrophied 
muscular fibre. 

The skin adapts itself to the conformation of the 
subjacent parts, being often cushioned in depres- 
sions, by adipose matter. 

The ligaments and capsules, like the muscles, 
are changed in form, dimensions, and texture. 
They may be actively retracted as well in con- 
genital dislocation as in other deformity. In ex- 



CONDITION OF THE MUSCLES. 191 

treme adduction of the foot, the internal lateral 
ligament of the tibio-tarsal articulation and the 
astragalo-scaphoidean ligament are sometimes re- 
duced to a third or a quarter of their normal length. 
In the same way the external lateral ligament of 
the knee offers an obstacle to the correction of in- 
ternal deviation of this joint. The ligaments are 
also subject to passive retraction, merely accommo- 
dating themselves to their approximated points of 
insertion. 

When extended, they become thinner and longer. 
Like the muscles they are subject to fatty trans- 
formation when in a state of continued repose, 
though in a less degree. In conditions which pro- 
duce the fibrous transformation of the muscles, the 
ligaments tend to become ossified ; a condition 
which is also the occasional effect of rest alone. 

The articular capsule of the femur when extend- 
ed gradually, acquires the form of a double cone 
united at their summits. 

In fine, the ligaments and capsules when retract- 
ed, offer invincible obstacles to reduction by unaid- 
ed mechanical force ; and when elongated, they 
constitute a serious impediment to any efforts to 
maintain this reduction. 

The cavity of the capsular ligament of the head 
of the femur, has been found to be obliterated in 
old subjects ; a fact upon which has been founded 
an argument against attempts at reduction. This 
condition does not exist in young subjects ; and is 
rarely a serious obstacle to reduction until the pa- 



192 CONGENITAL DISLOCATIONS. 

tient attains the age of twelve or fourteen years. 
The communication has been found to exist even 
in subjects of twenty, twenty-five, and thirty years 
of age. 

Alterations of the articular extremities. The head 
of the femur, for example, is diminished in size, 
while its neck becomes shorter and more horizon- 
tal. - It may be flattened or grooved, by pressure 
against the edge of the socket, or other neighbor- 
ing parts. 

When no longer lubricated by the synovial fluid, 
its surface loses its polish, and becomes rough, while 
the cartilage gives place to bone. 

Articular cavities. The cotyloid cavity is especial- 
ly the seat of alteration. It tends to become at once 
superficial, and triangular, in a manner correspond- 
ing to the triple formation of the os innominatum. 

The articular cavities tend to become obliterated, 
in proportion to their original depth, and the date 
of the lesion. This is effected in two ways. 1st. 
By the rising up of the bottom of the socket, which 
seems to result from the absence of pressure. 2. 
From the production of a cellular fatty tissue, ap- 
parently the hypertrophy and degeneration of the 
normal tissues of the base of the cavity. 

When the luxation is partial, the cavity yields to 
the continued pressure of the head of the bone in 
the direction of the force which it exerts. 

These conditions may be thus summed up, with 
reference to the reducibility of the luxation. 1. 
When the head of the bone has escaped from its 



CONDITION OF THE MUSCLES. 193 

socket, and no new socket has been formed, both 
the articular extremity and cavity proportionately 
diminish in size. This circumstance, while it facil- 
itates reduction, impedes subsequent movement. 
The reduction, however, tends to induce the parts 
to resume their normal size. 2. If the head of the 
bone has formed a new socket, it retains much of 
its original dimensions, a condition which hinders 
it from entering the atrophied socket, and prevents 
its reduction. 

3. The grooves and other irregularities in the 
conformation of the articulating extremity, inter- 
fere both with reduction and subsequent move- 
ment. 

4. After reduction, the articular deformities, and 
the relaxation of the capsules, facilitate the recur- 
rence of luxation. 

The changes both of bones and soft parts is 
gradual and slow, so that though these luxations 
become after a time irreducible, they are not so at 
first. Guerin has reduced congenital dislocation 
of the femur, of ten years' standing, and M. Guil- 
lard has reported a similar case of permanent reduc- 
tion of a scapulo-humeral luxation, in a girl of six- 
teen years of age. 

Congenital Dislocation is not due to a simple 
arrest of developement of the bony structure. If 
the bones be examined at an early period after lux- 
ation, they are found unchanged. 



25 



194 CONGENITAL DISLOCATIONS. 



ALTERATIONS OF PARTS IN THE NEIGHBORHOOD OF 
LUXATIONS. 

New articular cavities are sometimes formed, and 
sometimes not. They are rarely developed before 
the age of twelve or fourteen, but the period of 
their formation varies. In an old woman of seven- 
ty-three with double congenital luxation of the hip, 
one new cavity was formed, while the other side 
presented merely a slight depression. 

With regard to the conditions which aid in es- 
tablishing the new socket, M. Guerin declares it 
to be a law that such cavities are formed, only 
when the capsular ligament is ruptured, and the 
head of the bone is placed in contact with the bone 
upon which it lies. 

When the new joint is formed, the ruptured 
capsule contracts firm adhesions, which preclude 
all chance of displacing the bones, except by un- 
justifiable violence. 

When there is no new joint, the head of the 
bone is finally bound down by fibrous cords, which 
require subcutaneous division. 

Alterations of the skeleton. These are especial- 
ly observed near the hip. Contrary to the opinion 
of Dupuytren, the pelvis often suffers in these 
cases, as has been shown by M. Sedillot. 

When one femur is luxated upwards and out- 
wards, the pelvis of that side is carried upward, 
backward and outward. The whole pelvis is flat- 



INDICATIONS FOR REDUCTION. 195 

tened obliquely, the pubis being carried beyond the 
median line towards the healthy side. 

The os innominatum of the affected side be- 
comes more perpendicular, and that side of the pel- 
vis is elevated. 

INDICATIONS FOR REDUCTION. 

From examinations of the pathological confor- 
mation of the parts, in different stages of lesion, it 
results, that congenital luxations are reducible in 
certain conditions ; that they are less so in propor- 
tion to the degree and long standing of the deform- 
ity ; that they are wholly irreducible when very old, 
and principally when accompanied with new artic- 
ular cavities ; and, finally, that the permanence of 
the reduction is in proportion to its facility. 



MEANS OF PREPARING FOR, EFFECTING, AND CONSOLIDAT- 
ING, REDUCTION IN ALL ARTICULATIONS. 



1. Preparatory and continued extension, which 
counteracts the displacement due to superincum- 
bent weight, and brings into view the retracted 
muscles. 

2. The subcutaneous section of muscles which 
refuse to yield to extension. 

3. Continued extension of the ligaments; and 
their subcutaneous section if required. 

4. The reduction of the luxation. 

5. The consecutive treatment ; of which the in- 
dications are 



196 CONGENITAL DISLOCATIONS. 

1. Apparatus of extension to elongate the mus- 
cles and ligaments not divided, and to extend those 
which have been divided. 

2. Force so supplied as to maintain the articu- 
lar surfaces in contact, and to exercise continued 
pressure upon the part destined to form a new 
socket. 

3.' Gradual motion in imitation of the normal 
movement of the part ; to wear away as it were 
a depression for the articulations, and to establish 
its functions. 

4. An indication derived from the fact that the 
capsule must be ruptured, and the bones placed in 
contact before a new articulation can be estab- 
lished. 

M. Guerin therefore practices subcutaneous per- 
foration of the capsule, and scarification of the liga- 
ments, to promote an inflammatory action, which 
may induce their firm adhesion. 

In this way M. Guerin reduced the congenital 
dislocation of the sternal extremity of the clavicle 
in a girl of thirteen years of age, which had been 
repeatedly reduced, without success. M. Guerin 
scarified the capsular ligament, and repeated the 
operation at the end of ten days. The extremity 
of the bone was confined in its place, and in a 
month the ligaments were firmly retracted, and the 
arm was capable of executing its normal move- 
ments without luxation of the clavicle. 



RECENT AND CHRONIC DISLO 
CATIONS. 



The tendons not unfrequently form a serious 
impediment to the reduction of accidental disloca- 
tions of long standing, especially of the humerus 
and olecranon. They have been not unfrequently 
divided in these cases, by the subcutaneous opera- 
tion, and the limb has been thus replaced with 
comparative ease. 

The pectoralis major, latissimus dorsi and teres 
major and minor muscles, have been thus divided 
for the purpose of reducing a dislocation of the 
shoulder of long standing. 

I have seen M. Berard divide the tendo Achillis, 
for the purpose of facilitating the reduction of a 
recently dislocated foot. The foot was easily re- 
placed, and the patient subsequently recovered its 
use. Several similar cases are reported in the 
journals by this surgeon, and by other writers. 



193 DISLOCATIONS. 

In the reduction of a dislocation of the foot, of 
long standing, accompanied with the formation of 
an artificial tibia tarsal joint, M. Bonnet divided 
the tibialis posticus, the extensors of the toe, and 
of the great toe, and finally all the fibrous tissue of 
new formation. 



SECTION OF MUSCLES IN 
LOCKED JAW. 



Certain rare forms of this affection are due to 
bony anchylosis, for which M. Berard has proposed 
a section near the condyles analogous to that prac- 
tised in Barton's operation for anchylosed hip. 

The more common form results from muscular 
contraction. For such cases M. Bonnet 1 proposes 
the section of the masseter and temporal muscles, 
as an aid to ordinary mechanical means for sepa- 
rating the teeth. The masseter is best divided 
according to Bonnet, in its superior fifth. Below 
this point, it adheres to the lower jaw and is cover- 
ed behind by the parotid gland. The tenotome is 
entered at the anterior border of the muscle, just 
below the zygomatic arch, and carried behind it as 
far as the coronoid process of the lower jaw. The 
muscle is then divided from within outward. 



1 M. Bonnet effected the division of the masseter muscle, Oct. 16, 
1841. It had been performed by Dr. Schmidt of New York, the 8th 
of the same month. — Boston Med. and Surg. Jour., July, 1842. 



200 LOCKED-JAW. 

The temporal muscle may be divided above or 
below the arch. It is best divided below, unless, 
as in old patients, the coronoid process is so long 
as to impede the progress of the knife. The mus- 
cle may be always divided above the arch, but its 
substance is less tendinous, and the hemorrhage 
from the deep seated temporal artery is consid- 
erable. 

In the section beneath the zygomatic arch, the 
tenotome is entered at nearly the same point as for 
the section of the masseter, and directed towards 
the tuberosity of the superior maxillary. The 
blade is then passed backwards, between the ex- 
ternal pterygoid and the temporal muscles, until it 
reaches the articulation ; when the muscle is di- 
vided from within outwards. The coronoid pro- 
cess is occasionally an insurmountable obstacle to 
the section in this region. 

Above the malar bone the blade is entered just in 
front of the temporal artery, and carried to the 
bone, in contact with which it remains until it 
reaches the posterior part of the malar bone. The 
edge is then turned outwards and the muscle di- 
vided. Both the muscles may be simultaneously 
divided. 

In one case in which M. Bonnet applied these 
methods, a slight amelioration was obtained. The 
patient was old, and the affection of long standing. 

The operation of Dr. Schmidt was followed by 
immediate relief in locked-jaw of twelve years 
standing. 



SUBCUTANEOUS SECTION OF THE 
ORBICULAR MUSCLES. 



These muscles have been subcutaneously di- 
vided, with good results, for various affections. 
That of the mouth, for deviation of one of the an- 
gles, which assumed, after operation, its normal po- 
sition. 1 That of the eye, by Cunier, for ectropion. 
The sphincter of the anus, by Blandin, Brachet, 
and others, in cases of fissure of the anus. 

M. Phillips affirms that the orbicular muscles are 
not formed of circular, but of straight fibres, ob- 
liquely situated, and attached by one extremity to 
a median line, and by the other to an aponeurotic 
circle which surrounds them. 

This he infers from the irregular form of the 
mouth in the spasmodic action of its orbicular mus- 
cle, and from the fact that, in drawing upon the 

1 Phillips' Tenot. Souscut. p. 204. 



202 ORBICULAR MUSCLES. 

fibres, in any direction, the orifice is distorted and 
a chord instead of an arc is produced by the trac- 
tion. 

The relief obtained by the division of the orbic- 
ular muscle of the eye, in the case of ectropion 
above referred to, seems to confirm this theory. 



APPENDIX. 



In the treatment of deformity, it is common to take 
at the outset, a cast in plaster of the distorted region, 
which may be afterwards compared with a cast taken 
at a subsequent time. The result of orthopedic treat- 
ment is in this way readily appreciated. 

In casting entire limbs some little dexterity is requi- 
site. The tendency of the dried or anhydrous sulphate 
of lime to set, or form a solid hydrate when mixed with 
water, is well known, and most people are familiar with 
the general features of the process of casting in plaster. 
But there are some details connected with manipulation, 
in casting large masses, and in taking moulds from the 
living subject, which deserve to be mentioned. I have 
therefore written out the following description of the 
process, most of which I obtained, one morning, from 
the ' mouleur ' attached to Guerin's establishment. 

1. No tools are a substitute for the hand, which is 
in contact with the plaster during the whole process. 
The only utensils required are a stiff spatula of wood, 
or better of iron, a bowl, a chisel and mallet. 



204 APPENDIX. * 

2. The necessary quantity of plaster must be mixed 
at once. It is evidently better to exceed than to fall 
short of the required amount. 

3. The most convenient vessel is a basin or common 
earthen pan with flaring sides. Into this, water at the 
temperature of about 100 degrees 1 is first poured. The 
calcined plaster is then taken in large handsful, sup- 
ported by the open palm and fingers which are slightly 
separated, and gradually sprinkled into the water by a 
sort of successive undulating movement of the fingers. 
In this manner the water attacks each particle as it falls, 
and hinders the formation of lumps which are after- 
wards difficult to break up. The powder is equally 
distributed until it is so heaped up that it begins to ap- 
pear above the surface. Half a minute is then allowed 
to elapse to enable the water to penetrate it thoroughly, 
after which the mass is stirred with the spatula until it 
assumes, at the end of a minute, a uniform consistence 
of the density of thick syrup. It is then ready for use. 

The plaster is placed in contact with the object, of 
which a cast is desired, and when hard is removed. It 
then constitutes a mould into which a fresh quantity of 
plaster is subsequently poured. The last should pre- 
sent, when withdrawn, a fac-simile of the original. 

It is evident that solid objects require a mould of 
several pieces, which multiply in proportion to the com- 
plicated form and unyielding material of the model. 
Flesh and other soft tissues yield to the projecting an- 
gles of the mould ; and the number of its pieces is 
thus considerably diminished ; so that it is rare that a 
human limb or trunk requires a mould of more than 
two pieces. 

i Cold water subjects the patient to unnecessary exposure. 



APPENDIX. 205 

The divisions are made by means of a strong thread 
which is applied to the limb before the plaster is laid 
on ; and being withdrawn by its loose ends when 
the plaster is half hardened, it cuts its way out and 
bisects the mould. The position of the string as a 
general rule is as follows : 

1. On the leg, from the superior insertion of the rec- 
tus muscle over the patella, along the tibia to the outer 
side of the great toe, and by the centre of the sole, heel, 
and ham, to the tuberosity of the ischium. A better di- 
vision is from the great trochanter to the head of the 
fibula, centre of the external malleolus, thence on the 
external edge of the foot to the edge of the little toe, 
and the end of the great toe ; then back to the internal 
malleolus, the internal condyle of the femur and the 
superior insertion of the adductor muscles. 

2. The arm is divided by a line from the region of 
the pectoral on the side to the styloid processes of the 
pronated radius and by the radial edge of the hand and 
the tips of the fingers to the styloid and coronoid pro- 
cess of the ulna and the region of the deltoid. If the 
fingers be separated, the string is to be carefully carried 
to the base of each, upon the edge which separates the 
palmer and dorsal surfaces. 

3. Upon the trunk, the line passes over the back of 
the neck a little before one shoulder to the great tro- 
chanter on one side, and behind the other shoulder to 
a point just behind the trochanter of the opposite side. 

The action of respiration commonly breaks the mould 
upon the anterior surface of the trunk, and the pieces 
are to be subsequently put together. 

4. The mould of the head requires but two pieces, 
separated before and behind on the median line, or, 
which is better, by a line through the vertex passing 



206 APPENDIX. 

before one ear and behind the other. Such an oblique 
division obviates the difficulty presented by correspond- 
ing prominences on opposite sides of the original. They 
are thus distributed between the two halves of the 
mould. The hair is covered by an oiled napkin and 
the ears are plugged with cotton. 

The head is commonly included in a cast of the neck ; 
a perpendicular position is necessary. The soft plaster 
then flows off from the sides of the nose without ob- 
structing respiration. In the horizontal position, quills 
or paper tubes are adapted to the nostrils. 

A perpendicular position is required to display the 
action of the muscles of the neck or trunk, while the 
limbs may be cast horizontally. When permanently 
flexed, the plaster is kept in contact with their inferior 
surface, by a sort of bed formed by a sheet of stiff paper 
supported by straw. 

As a slight motion breaks the plaster before it is hard- 
ened, young children require to be confined during the 
process. 

If a leg for example, is to be cast, the plaster is pre- 
pared as before indicated, some of the thinner plaster is 
then applied with the hand to the external and internal 
surfaces of the limb, and by means of this the string 
is made to adhere, care being taken to bring it in con- 
tact with the skin at every point. The limb is then 
gradually covered, and the plaster as it thickens, is ap- 
plied with the hand till it attains a depth of from one 
to three inches. The string is withdrawn while the 
plaster is yet soft, and the mould thus divided is allowed 
to harden. The mass grows warm j and it is just be- 
fore its maximum heat, when a fragment pressed be- 
tween the thumb and finger breaks as if dry and brittle, 
that it is to be taken off, If the plaster by accident 



APPENDIX- 207 

becomes too hard, so that the string breaks, the mould 
is to be broken with a chisel and mallet, and the frag- 
ments are subsequently united, by a layer of plaster 
applied to the outside. 

In casting the back, the model is seated upon a table 
and the hairs of the neck being matted together with 
soft soap, the plaster is applied with the hand to the 
upper part of the neck and shoulders and allowed to 
stream down the back. As it attains consistence it ad- 
heres to the skin and may be built up. 

The interior surface of the mould thus formed is im- 
mediately painted over with a mixture of soft soap and 
water, and when saturated, the superfluous soap is re- 
moved, and a thin coat of oil applied. If composed of 
pieces, these are united and the mould is then ready for 
the cast. Plaster is prepared as before, without delay, 
poured into the interior, and allowed to set. 

At the expiration of fifteen minutes the mould must 
be broken off in small fragments with a chisel and mal- 
let, and is hence said to be lost, {stampa persa.) Du- 
ring this operation the cast is held in the lap, and the 
blows should be given in the direction of the axis 
which presents the greatest inertia. The mould is 
thus readily detached ; its entire superior surface being 
removed before the base is attacked. 

If the cast be not immediately made, the mould be- 
comes dry and must be soaked in water before the ap- 
plication of the soap. If the operation be delayed for 
several days, the plaster of the mould becomes so hard 
as to be with difficulty broken. If the cast be allowed 
to remain a few hours in the mould the oil is absorbed 
and the surfaces are with difficulty detached. 

If a duplicate cast be desired, a permanent mould 
{stampa buona) is made upon this first cast, which then 



208 APPENDIX. 

serves as the model. The model is well oiled and plas- 
ter is applied in small masses each capable of being de- 
tached from its various curves and angles. The first 
piece is detached and its edges squared with a sharp 
knife after which it is oiled and replaced to aid in the 
formation of the next. These fragments are numerous 
when the model is complicated. Drapery, and the stat- 
uettes, which are common in the shops, sometimes re- 
quire several hundred, which are kept in place by an 
outer covering or garment (camisia) of plaster in large 
fragments. When dry the mould is heated and satu- 
rated with boiled linseed oil at a high temperature. 
This gives tenacity to the plaster, and presents when 
cold a polished surface, which needs only to be oiled 
when a cast is required. The pieces are detached in 
the inverse order of their formation, and such a mould 
yields an indefinite number of casts. 



REFERENCE TO PLATES, 



STRABISMUS. 

Fig. 1. Speculum for upper or lower Lid. 
" 2. Hook for Conjunctiva. 
" 3. Double do. for Sclerotic. 

" 4. « Crotchet-bistouri ' ot Baudens with porte-sponge. 
" 5. Blunt Hook of Dieffenbach. 
'.* 6. Tenotome of Guerin, (see p. 26.) 
" 7. Side view of do. 
" 13. Snowden's blephareirgon modified. 

TENOTOMY. 

Fig. 8. Common pointed Tenotome. 
" 9. " blunt do. 
" 10. Myotome for Dorsal Muscles. 
" 11. Front view of do. 

" 12. Guerin's Tenotome for Sterno-Cleido-mastoid Muscle. 
" 13. Self-acting Speculum for Lids. 

CLUB-FOOT. 
Equinus. 
Fig. 14. Foot-board of Stromeyer. (see p. 107.) 
" 15. Scarpa's Boot, (see p. 102.) Sole of do. 
«' 16. \ 

" 17. \ Graduated Movement. 
" 18. ) 

Varus. 
«• 19. Contrivance for reducing Varus to Equinus. (see p. 108.) 
" 20. Dieffenbach's do. (see p. 109.) 
27 



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